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THE PELVIC INLET. 

(From a PJwtograph. ) 




How to Use The Forceps. 



INTRODUCTORY ACCOUNT 



FEMALE PELVIS 



AND OF THE 



Mechanism of Delivery. 



BY 

HENRY G. LANDIS, A.M., M.D., 

PROFESSOB OF OBSTETRICS AND DISEASES JOF WOMEN AND CHILDREN 
IN STARLING MEDICAL COLLEGE, COLUMBUS, O. 

Revised and Enlarged by 
CHARLES H. BUSHONG, M.D., 

ASSISTANT GYNECOLOGIST AND PATHOLOGIST TO DEMILT DISPENSARY, 
NEW YORK. 



ILLUSTRATED. 







NEW YORK: 
E. B. TREAT PUBLISHER, 5 COOPER UNION. 

1894. 

Price, $1 .75. 



h= 







KG W 



Copyright, 

By E. B. TREAT, 

1880-1894. 



PREFACE 

TO THE REVISED AND ENLARGED EDITION. 



Some of the statements made by the late Prof. 
Henry G. Landis in the following pages differ radi- 
cally from the accepted teaching and teachers. Yet 
they have in their support, in addition to the numer- 
ous authorities he has quoted, their agreement with 
the known anatomical facts given in their elucida- 
tion, with phenomena familiar to every well posted 
obstetrician, and with mathematical mechanics, making 
their truth easy of demonstration. After a careful 
perusal of the book and the demonstration of its truths 
in actual work at the bedside, I have consented to 
edit this new and enlarged edition, believing with 
the publisher that the book contains much of value, 
and that the science of midwifery will lose greatly by 
permitting it to pass from the further notice of the 
medical profession. 

C. H. BTTSHONG, M.D. 

New Yokk, 59 W. 19th St., January, 1894. 



PREFACE. 



The views herein set forth of the Anatomy of 
the Pelvis were imperfectly outlined in an article 
published in The American Journal of the Medical 
Sciences for April, 1876. Further study and expe- 
rience in teaching have led to their expansion into 
what is now, I trust, a more exact and intelligible 
statement. The practical deductions which arise 
from them are given with as much conciseness as 
possible. 

It has not been thought necessary to present an 
array of authorities and opinions of others as to 
the manner of using the Forceps when the stand- 
point of observation was obviously different. With 
this disclaimer of improperly ignoring the labors of 
others in this field, these pages are submitted to 
the profession for the test of an enlarged experience. 

H. G. LANDIS. 
Columbus, 0., Sept., 1880. 



INTRODUCTION. 



The right use of the obstetrical forceps demands 
a thorough knowledge of four things : First, of the 
instrument itself, its form, design, and capabilities ; 
second, of the place into which it is to be intro- 
duced, viz.. the maternal passages, their form, direc- 
tion, and mutual relations ; third, of the body upon 
which they are to be applied, viz., the child's head, 
its form, consistence, and tolerance of manipulation : 
fourth, of the normal mechanism of labor, or the 
manner in which the child should be delivered by 
the natural powers — for the forceps are not a foreign 
and unnatural resort, like the Caesarean section, but 
are intended to assist, supplement, and conform to 
the course naturally observed in labor. The great 
diversity in the shape and design of forceps now in 
use, and the vague and conflicting opinions as to the 
manner of their employment are a sufficient evidence 
that an exact and scientific basis has not yet been 
reached or, if known at all. that it has not been well 
and generally understood. A study of the mechan- 
ism of labor cle novo, will be. then, the first requisite 
for a proper understanding of any artificial aid in- 
tended to assist or replace that mechanism. I shall 
take for granted a preliminary acquaintance with the 
superficial anatomy of the pelvic bones. 



CONTENTS. 



Introduction, 11 

PAET I. — The Mechanism of Labor. 

Section 1. The Anatomy of the Pelvis, . . . .15 

Section 2. The Propelling Forces, .... 34 
Section 3. The Body to be Propelled, . . . .39 

Section 4. The Mechanism of Delivery, ... 45 

I. The Vertex. 1. In the First Position, . . 46 

*} In the Second Position, . 65 

3. In the Third Position, . . 66 

2. First Mechanism, . 67 

b. Second Mechanism, . 72 

c. Third Mechanism, . 73 

d. Fourth Mechanism, . . 76 

4. In the Fourth Position, . 78 

II. The Face. 1. In the First Position, . . 81 

2. In the Second Position, . 85 

3. In the Third Position, . . 85 

4. In the Fourth Position, . 87 

PART II.— The Forceps. 

Introductory, 91 

1. The Blades, 94 

a. Head Curve, 95 

b. Pelvic Curve, 97 

2. The Handles, 99 

3. The Lock, 100 



8 CONTENTS. 

PAGE 

The Application of the Forceps, .... 103 

I. At the Inlet 104 

II. At the Outlet, 117 

III. On the After-coming Head, . . . . 118 

IV. General Remarks, 119 

Traction, 121 

Compression, 134 

Leverage, 135 

a. Flexion, 140 

b. Rotation, 142 

"When to Use the Forceps, 146 

I. During the Second Stage, .... 147 
II. During the First Stage 160 

III. For certain Accidents of Labor, • . . 164 

IV. For Secondary Purposes, 165 

PAET III. — Application and Cases. 

Critical Remarks, . 171 

The Perineal Body, 176 

The Use of the Forceps, . . . . . 179 

Preparation for their Use, 185 

Symphyseotomy, 188 

Illustrated Cases, 191 



PART I. 



The Mechanism of Labor. 



SECTION I. 

THE ANATOMY OF THE PELVIS. 

The mechanism of labor is concerned wiih three 
things. 1. A body to be propelled. 2. A tube or 
channel through which it is propelled. 3. The for- 
ces which accomplish and regulate the propulsion. 

The first is the child, and chiefly the child's head, 
which alone offers much resistance. The second is 
contained mainly in the pelvis. The third is mainly 
of muscular origin. The relations which these sev- 
eral factors bear to each other, and especially those 
subsisting between the first and second, constitute 
the most important part of the study of this mechan- 
ism. Neither of these can be profitably studied apart 
from the other except in so far as they may present 
conditions alien to the mere fact of delivery. As a 
starting-point we may take the most permanent fac- 
tor, the pelvis. 

The female pelvis has three uses : 

I. It serves to contain and protect certain vessels 
and viscera. 

II. Being placed at the end of the vertebral col- 
umn it is designed to support the weight of the body, 



16 HOW TO USE THE FORCEPS. 

transmitting it to the femora in the erect position 
and to the ischiatic tuberosities in the sitting posture. 
III. It is modified to allow and direct the passage 
of the child through it during labor, and is the prin- 
cipal constituent of the parturient canal. The first 
use is obvious, and is not relevant in this connec- 
tion. The second is not entirely relevant, and may 
be dismissed with this brief formulation, which the 
practically minded reader may omit. 

1. The pelvis is made up, first, of two beams, the 
sacro-iliac, extending laterally from the base of the 
vertebral column to the acetabulum of either side 
and thus distributing the weight of the body to the 
femora in the erect posture. 

2. These lateral beams are continuous with a 
third beam, the pubic, placed transversely, and in 
front, which regulates the interval between them. 

3. These three beams in the adult female are 
arched outwardly to provide room for the parturient 
act, and are so situated as to form a complete bony 
rim at the beginning of the pelvis. 

4. From the under side of this rim two other 
arched beams spring, the ilio-sciatic, one on each 
side and posteriorly, which end in the ischial tuber- 
osities, to which they transmit the weight of the body 
in the sitting posture. 

5. A sixth arched beam, the sub-pubic, is placed 
under the bony rim in front, which also has its ex- 
tremities in the ischial tuberosity of either side. 



THE ANATOMY OF THE PELYIS. 17 

6. The upper bony rim is amplified into a tube by 
the presence of these secondary arched beams on the 
front and sides, and by the extension of the sacrum 
and coccyx behind. 

Thus we see that the pelvic tube is not entirely 
designed as a parturient canal, but that a structure 
having other uses has been modified for this second- 
ary purpose. The extent of the modification can be 
seen by comparing the male and infantile pelves with 




Pig. 1.— Outlined from Hodge. 

that of the adult female, the beams of the former be- 
ing nearly straight, while those of the female are 
greatly arched. And if it is modified for the sake of 
the child, we may expect to find a correspondence 
between the shape of the pelvis and the shape of the 
child. Before making the comparison, we will no- 
tice that the wings of the ilium and sacrum are con- 
cerned only with the first and second uses of the 
pelvis, being buttresses of the arched beams and 
guards of the viscera against external violence. The 



18 



HOW TO USE THE FORCEPS. 




Fig. 2. 



obstetrical relations of the pelvis begin with the bony 
rim before mentioned. We may therefore remove 

these wings as a 
preliminary to our 
study. When the 
sacral and iliac 
wings, or " false pel- 
vis," are removed, 
the pelvis presents 
the appearance 
shown in Fig. 1, 
when viewed from in front. If we then make a 
perpendicular section through the acetabula we shall 
find that the pelvic tube has an outline similar to 
that shown in the diagram Fig. 2. It is therefore 
wider above than below, which is the first important 
fact to remember. 
This does not give 
us a complete idea of 
the tube, for the sac- 
rum which forms its 
posterior wall is 
markedly curved. 
We must therefore 
make another per- 
pendicular section at 
right angles to the 
former one, which will give us such an outline as is 
shown in Fig. 3. By combining these mentally, for 




Fig. 3. 



THE ANATOMY OF THE PELVIS. 19 

obviously no pictorial representation can show them 
at once, we will begin to have an approximate 
idea of the shape of the pelvic tube. But we 
would, if we stopped here, have an idea that it 
resembled a funnel bent upon itself, and would 
fail to have any explanation why the child in labor 
does not at once drop to the bottom, since the 
top of the funnel is so much more capacious than 
the lower end. From these two sections we learn 



coccyx 





Fig. 4.— The Pelvic Inlet. Fig. 5.— The Pelvic Outlet. 

only the direction of the tube ; its calibre must be 
determined by looking into and through it. Its be- 
ginning or inlet is found to have the shape indi- 
cated in Fig. 4 ; its outlet, that shown in Fig. 5, a 
remarkable difference. These four figures (2, 3, 4, 
5) show the pelvis from in front, from the side, the 
inlet and outlet, and must be held in mind while we 
seek for a something to harmonize and explain them. 
Beginning with the inlet, we find that its shape 
is often spoken of as an irregular oval, but when 



20 HOW TO USE THE FORCEPS. 

we analyze it we will find that it is beautifully 
regular in outline. The explanation of its shape 
must be sought, as said before, in the child, for 
which the pelvis has been modified. Clinical expe- 
rience teaches us that the child's head is the part 
which offers the most resistance in delivery. Its 
great relative size and firm organization make it the 
most difficult part to be expelled. Also, it is usually 
in advance, and after its passage through the pelvis 
the rest of the body can readily follow. Next to the 
head the shoulders offer the largest outline. Only 
under exceptional and abnormal circumstances do 
any other parts of the child present any difficulty in 
passing through the pelvis. The natural manner for 
the child to enter the pelvis in labor, is with the top 
of the head in advance. 

The middle circumference of the head is there- 
fore applied to the brim or inlet at the beginning of 
labor. If a plane section be made 
through the middle of the head 
horizontally and at the level of 
the parietal eminences, it will be 
bounded by such an outline as is 
shown in Fig. 6, which is for all 
practical purposes an ellipse. As 
a matter of fact, if the head is 

Fig. 6.— Outline op 

fostai, head. partially flexed upon the breast, a 
horizontal section made at the same level will be 
entirely elliptical. If we apply an ellipse cut out of 





THE ANATOMY OF THE PELVIS. 21 

card-board and having such an outline, to the inlet 

of the pelvis we will find that it completely coincides 

on one side, and if reversed, to the opposite side, the 

two outlines intersecting one another. This is shown 

in Fig. 7, where the 

dotted line A B finishes 

the elliptical outline on 

one side and the line 

A C upon the other side. 

The same ellipse applied 

to the outlet entirely 

corresponds to it, though 

the outward flaring of the ischial tuberosities makes 

this a little wider. 

We may then say, tentatively, that the outline of 
the inlet is compounded of two partially superim- 
posed ellipses similar to the outline of the foetal head 
— while the outlet represents but one such outline. 
The shoulders will throw more light upon the sub- 
ject. They also have upon transverse section an el- 
liptical outline almost identical with that of the head. 
But the long diameter of the shoulders, i.e., their 
breadth, is at right angles to the long diameter of 
the head. Therefore, when these two ellipses are su- 
perimposed, as happens practically when the shoul- 
ders follow the head through the pelvis, their outline 
would present such an appearance as is shown in 
Fig. 8. 

This is not the whole truth. The foramen mag- 



22 



HOW TO USE THE FORCEPS. 



num, and therefore the occipital condyles, are not 
placed centrally in the base of the child's skull, but 
much nearer the posterior end of the head, especially 





Fig. 8. Fig. 9. 

when the head is flexed. Therefore, Fig. 9 may be 
substituted for Fig. 8 as more exactly representing 
the facts. Now if the head is laterally flexed so as 
to bring one ear nearer to the corresponding shoulder 
than in the horizontal position, which also happens 
during the labor, these outlines would be superim- 





Fig. 10. 



Fig. 11. 



posed in the manner shown in Fig. 10, which also 
represents the outline of the pelvic inlet (Q.E. D.). 
The length of the pelvis is such that the shoulders 



THE ANATOMY OF THE PELVIS. 



23 



may still remain in the upper part when the head is 
born. If it were not for some such provision the 
neck would be disagreeably twisted, by reason of the 
shoulders being compelled to follow the head through 
a passage calculated for the latter alone. Further- 
more, transverse sections of the pelvic tube made at 
any point will show this double relation until we 
reach the outlet, where 
there is evidently but a 
single canal. Fig. 11 
shows the outline of 
the canal a little above 
the outlet. By the time 
the shoulders have 
reached this point the 
head is born. 

We may therefore 
infer that the pelvis is 
in reality a double canal, 
its two parts being par- 
tially fused at the be- 
ginning and entirely so fig. 12. 
at the end, and may construct a theoretical diagram, 
Fig. 12, which will exhibit these facts. This will 
explain the appearance delineated in Fig. 2, for on 
adding dotted lines to represent the inner and in- 
visible walls of these supposed parts, as in Fig. 13, 
we see why the pelvic inlet is wider than the outlet, 
and also learn the direction of the two canals. 




24 



HOW TO USE THE FOECEPS. 



These facts may be formulated as follows, before 
proceeding further, with such conclusions as may 
warrantably be drawn from them. 

I. The pelvis contains two canals, partially sepa- 
rate at the beginning and identical at their termina- 
tion. 

II. These canals converge from above downwards, 
and are also mutually curved from before backwards, 

as indicated in Fig. 
3. Their direction 
is therefore some- 
what spiral. 

III. The calibre 
of each canal is that 
of the foatal head ; 
therefore the head 
may descend in 
either canal and will 
follow a spiral course in so doing. These canals may 
be called respectively the right and left canals ; the 
right being the one in which exclusively the right 
sacro iliac symphysis is found, and the left in which 
the left sacro iliac symphysis is found. Of these the 
right is somewhat the larger and is the one in which 
the head usually descends ; for which there are other 
reasons, as will be shown further on. 

For purposes of description certain planes, axes, 
and diameters are to be considered, concerning 
which we will first state the views generally enter- 




THE ANATOMY OF THE PELVIS. 



25 



tained. Playfair says :* "By the planes of the pel- 
vis are meant imaginary levels at any portion of its 
circumference. If we were to cut out a piece of 
card-board so as to fit the pelvic cavity, and place it 
at the brim or elsewhere, it would represent the pel- 
vic plane at that particular part, and it is obvious 
that we may conceive as many planes as we desire." 
Two such planes are of especial importance, those of 
the inlet and outlet, 
or, as they are also 
termed, the superior 
and inferior strait. 
Hodge defines the 
plane of the superior 
strait as a surface 
bounded by the cir- 
cumference of the 
strait which is marked 
by the " inuer margin 
of the tuberosity or 
horizontal portion of the pubes on either side, by the 
spinous process, the liuea ilio-pectinea, and the inner 
margin of the ala of the sacrum, and posteriorly by 
the promontory of the sacrum." The axis of this 
plane is a line drawn at right angles to it and the 
combined axes of similar planes drawn at all levels of 
the pelvic cavity, constitutes the axis of the pelvis, 
which is supposed to indicate the course of the 
child's head in delivery (see Fig. 14). 
* System, p. 35-6. 




Fig. 14. 



26 HOW TO USE THE FORCEPS. 

By beginning wrong we generally end wrong. 
By studying the pelvis only from antero-posterior sec- 
tions we get only a partial knowledge of it. The 
whole study of the mechanism of labor as given by 
Hodge and his successors is vitiated by the inac- 
curacy involved in his description of the superior 
strait. For to this succeeds, as a consequence, a 
vagueness as to the true position of the head in labor 
— which is a point of great practical importance, es- 
pecially when we attempt to apply the forceps. To 
begin on common ground, the plane of the inferior 
strait is confessedly artificial and arbitrary. The 
outlet is so irregular in its termination that no one 
pretends to describe a plane passing through all the 
points of its circumference. We draw a line from 
the under edge of the symphysis pubis to the tip of 
the coccyx, called the conjugate diameter of the out- 
let, and a plane passing transversely through this line 
and limited by the calibre of the pelvis, we call the 
plane of the inferior strait. Since this calibre is so 
evidently the same or nearly so as that of the foetal 
head, and since we find clinically that the head 
emerges from the outlet in a definite relation with 
such a plane, we may retain it, but always admitting 
its artificial character and boundary. The same 
course has not been followed with the inlet. Hodge 
gives no hint of compromise in fitting the plane of 
the superior strait in its circumference, although 
Fig. 1, outlined from his work, shows clearly enough 



THE ANATOMY OF THE PELVIS. 27 

that no plane can pass through the points mentioned 
in his definition. And as unnoticed error, especially 
when sanctioned by high authority, has a great power 
of growth, it is not surprising to find Dr. Leishmann 
following with the statement that the various parts 
of the line bounding the superior strait " are in 
man alone on the same plane." As a matter of fact, 
the circumference of the inlet bounds two distinct 
planes, whose inclination to each other may be seen 
in Figs. 1 and 2 to be about at an angle of 150°. 

If we cut out of card-board two ellipses similar in 
outline to the middle circumference of the foetal head 
and apply them or attempt to apply them to the 
border of the pelvis on each side — in other words to 
the very points mentioned above by Hodge — we will 
find that they intersect one another in the median 
line, while accurately fitting the pelvis in other re- 
spects. We may call these planes respectively the in- 
itial plane of the right and left canal. Any number 
of similar planes may be drawn in each canal, which 
will have a less and less inclination to each other 
until at the inferior strait they will be identical with 
each other and with the plane of the inferior strait 
as above described. The axis of the initial plane of 
either canal is a line drawn at right angles to that 
plane, and indicates the direction of either canal at 
the beginning. 

The axis of each canal will be a line extending 
from the centre of its initial plane centrally through 



28 HOW TO USE THE FORCEPS. 

the canal to the centre of the plane of the inferior 
strait. This line will not have only the direction 
shown in Fig. 13, but being curved from before back- 
wards, in the manner of the central axis in Fig. 14, 
will be spiral and therefore incapable of pictorial rep- 
resentation. But there is upon the pelvic walls a 
line on either side, which is as nearly as possible par- 
allel to this axis, viz., the raised line extending from 
each pectineal eminence on the ileo-pectineal line to 
the ischial spine of the same side. As this is an im- 
portant line from this circumstance, and from the 
part it plays in the mechanism of labor, we may give 
it a name and call it the ilio-sciatic line. 

It will be convenient for descriptive purposes to 
retain the so-called " plane of the superior strait," 
but for avoidance of confusion we may define it as 
passing transversely through the conjugate diameter 
(CD, Fig. 15) of the inlet and call it the plane of the 
conjugate diameter. Similar planes may be conceived 
of as drawn at right angles to the general cavity of the 
pelvis at any level, and to distinguish them from like 
planes drawn in the right and left canals we may call 
them planes of the pelvic cavity. The plane of the 
conjugate diameter is said to be inclined to the hori- 
zon at an angle of 60° when the woman is in the 
erect posture, the face of the pubes looking almost 
directly downward and the plane of the outlet back- 
wards and downwards. In the sitting posture, with 
the pelvis resting on the tuberosities of the ischia, the 



THE ANATOMY OF THE PELYIS. 29 

inclination of the plane of the conjugate diameter is 
about 45°, while the plane of the outlet is almost hor- 
izontal and looking directly downwards. 

In the recumbent posture the plane of the conju- 
gate diameter is almost equally inclined in an oppo- 
site direction from the last, the plane of the outlet 
being nearly vertical. In the semi-recumbent pos- 
ture, which is supposed to be the characteristically 
American method of sitting, the plane of the conju- 
gate diameter is level with the horizon, while that of 
the outlet looks downwards and forwards. The in- 
itial planes of the right and left canals have substan- 
tially the same inclination to the horizon as the plane 
of the conjugate diameter in these various positions, 
so far as the planes are considered in their antero- 
posterior direction. Bat they have also a lateral 
obliquity of about 15° from that of the conjugate di- 
ameter, which is made sufficiently evident by refer- 
ence to the figures or better still, to the pelvis itself. 
Certain diameters are usually described as existing 
in the inlet and outlet of the pelvis. 

The principal ones in the inlet are the two ob- 
lique diameters and the conjugate. The oblique 
diameters are drawn from the sacro-iliac symphysis 
of either side to a point slightly in advance of the 
pectineal eminence of the opposite side (Meadows). 
In Fig. 15, AB represents the right oblique diameter 
(according to the German nomenclature), and EF, 
the left oblique. If we apply to the inlet a piece of 



30 



HOW TO USE THE FORCEPS. 



card-board cut after the pattern of the elliptical out- 
line of the foetal head, as delineated in Fig. 6, we 
will see that the long diameter of such an ellipse cor- 
responds with the oblique diameter of the canal in 
which it is inserted, while the short diameter of the 
ellipse lies in the line of the opposite oblique diam- 
eter. These diameters are nearly or quite fi>e inches 

loug in the normal pelvis, 
and are longer than any 
other which can be drawn 
in the pelvic brim, except 
in some cases the one ex- 
tending directly across it 
and known as the trans- 
verse diameter. The 
conjugate diameter CD is 
drawn from the promontory of the sacrum to the 
middle of the top of the symphysis pubis, and is the 
shortest, being about four inches in the normal pel- 
vis. Two others should perhaps be mentioned here, 
which are the ones drawn across the base of each 
sacro-iliac arch and called the sacro-cotyloid. 

Apart from any consideration of the doubleness 
of the pelvis, it is generally recognized that the head 
will enter the inlet with the greatest economy of 
space when its long or occipito-frontal diameter co- 
incides with one of the oblique diameters of the pel- 
vis, while its transverse or short diameter has an 
equal amount of room in the opposite oblique diam- 




THE ANATOMY OF THE PELVIS. 31 

eter. At the outlet the antero-posterior or conju- 
gate diameter extends from the under edge of the 
pubes to the tip of the coccyx, but a little reflection 
shows that it is the representative of the upper 
oblique diameters. Thus, if a rod be placed in the 
inlet coincident with the right oblique diameter, and 
its central point carried downwards in the axis of the 
right canal, its posterior extremity will traverse a 
line from the right sacro-iliac symphysis to the tip 
of the coccyx, while its anterior end will follow a 
similar line from a point in front of the left pecti- 
neal eminence to the centre of the under edge of the 
symphysis pubis, and the rod will then lie in the 
conjugate diameter of the outlet. For the rod, 
substitute a foetal head with its long or antero-pos- 
terior diameter in coincidence with the right oblique 
diameter of the inlet and the correspondence of the 
head to the right canal throughout will be entirely 
manifest. The same may be affirmed of the left canal, 
with a corresponding change of right to left, and so on. 
The bony pelvis, with its ligamentous and mus- 
cular additions, does not comprise the whole of the 
parturient canal, but at the inferior strait begins that 
part of it which is made up only of the soft parts. 
The latter is only temporarily fitted for this use, and 
has no fixed calibre, axis, or diameters, which are 
regulated by the size and shape of the foetal head 
and the direction taken by it. It is enough at pres- 
ent to conceive of it as an elastic tube through which 



32 



HOW TO USE THE FOKCEPS. 



the nead passes after being delivered from the pelvic 
canal. Besides the soft parts at its termination the 
uterus also may be said to form a part of the partu- 
rient canal, since the child in passing out of it must 
have its original direction controlled to a great ex- 
tent by the position of the uterus. The uterus, dur- 
ing labor, is not placed directly in the median line. 




Fig. 16. 

From various causes, among which the prominence 
of the lumbar vertebras is conspicuous, it is some- 
what deflected towards one side or the other of the 
median line, and in the majority of instances towards 
the right side. Viewed laterally the womb appears 



THE AXATOZtfY OF THE PELVIS. 33 

to be situated with its axis in the same line with that 
of the plane of the conjugate diameter. This is the 
statement usually made ; but when we perceive this 
obliquity we recognize that this cannot be, and that 
the axis of the uterus in labor is in the majority of 
instances continuous with the axis of the initial plane 
of the right canal (see Fig. 16). 

If, then, the child is disposed in the womb with its 
long axis coincident with that of the womb, it will be 
situated in the most favorable manner for entering 
the right canal. And the same might be affirmed of 
the left canal if the womb was in a condition of left 
obliquity. Since it is rarely found in this condition, 
and since we find clinically that the head is found 
with similar infrequency in relation with the left 
canal, we derive additional proof of the doubleness 
of the pelvis and of the existence of such planes and 
axes as have already been described. 



SECTION II. 

THE PROPELLING FORCES. 

The forces concerned in the mechanism are of 
two kinds, propulsive and guiding. The former are 
furnished by the contraction of the uterine muscular 
fibres and by the voluntary and semi-voluntary con- 
tractions of the abdominal muscles, but not exclu- 
sively. The force of the uterine contractions is 
communicated to the vertebral column of the child 
and acts primarily in the long axis of the womb. 
They therefore tend to propel the child in the axis of 
the initial plane of the right canal in the majority of 
instances ; or when the womb has a left obliquity in 
that of the opposite canal. So far as the uterus is 
concerned, therefore, the child tends to move through 
the pelvis in the direction of the line AB, in Fig. 16. 
The abdominal muscles transmit force in the same 
manner to the child, but in the median line when 
they act uniformly. Hence they are well designed 
to propel the child after it has reached the inferior 
strait and has finished its oblique course in the right 
or left canal. And as a clinical fact, we find that 
the action of the abdominal muscles is not, as a rule, 



THE PROPELLING FORCES. 35 

called into effect until the head has attained this 
stage. But from the inclination of the pelvis to the 
vertebral column, each of these forces, the uterine 
and abdominal, tends to propel the child to points 
behind the centre of the plane of the outlet. The 
abdominal muscles acting primarily in the axis of the 
plane of the conjugate diameter, impel it towards 
the tip of the coccyx. The uterine force tends to 
impel it to the same point ; perhaps a little to one 
side, but as far back. 

These tendencies are modified by the directive or 
guiding forces reflected from the sides of the canal, 
which being spiral or screw-like in shape consist es- 
sentially of continuous inclined planes. From the 
pelvic outlet to the vaginal outlet the head follows a 
very different course, emerging from the latter in a 
direction which forms an acute angle with the pro- 
duced axis of the plane of the conjugate diameter. 
It is obvious that the same force cannot act in two 
directions, one of which is almost the reverse of the 
other. There must be, then, a new force beyond the 
pelvic outlet acting in a different direction. This 
we find in the perineum. 

The superficial or anatomical perineum is the 
space bounded between the posterior vaginal commis- 
sure, the anus, and the ischial tuberosities. The 
deeper structures of this area consist of certain mus- 
cles and fibrous tissue, and most important of all, 
the perineal body. They are placed in front of or 



36 



HOW TO USE THE FORCEPS. 



opposite to the pelvic outlet, constituting the floor of 
the pelvis. The mechanical action of the whole 
structure may be studied in that of its principal 
part. The perineal body is a stout fibrous band ex- 
tending from one tuber ischii to the other. It is 
made of elastic fibrous tissue, and both for strength 
and elasticity is comparable to no other tissue of the 




Fig. 17. 



body unless perhaps the ligamentum nuchas. On sec- 
tion it appears wedge-shaped, being inserted between 
the vagina and rectum at their termination, with the 
edge directed upwards. It extends backwards as far 
as the coccyx — being covered and supplemented by 
sundry muscles of more or less importance in this 
connection, but having substantially the same me- 
chanical purpose in labor. 



THE PROPELLING FORCES. 37 

When the combined propulsive and directing 
forces have brought the head to and nearly through 
the pelvic outlet, it is met by the opposing force ex- 
isting in the elastic resistance of the perineal body 
assisted by the associated structures of the pelvic 
floor. The latter force acts in a direction nearly 
opposite to the former, and the head is, therefore, 
directed forward in the line of the resultant of the 
two forces. In Fig. 17 the arrow A represents the 
direction in which the original forces bring the head 
upon the perineum : B will represent the line of the 
direction impressed upon the head by the perineal 
force alone, and will show the resultant of the two. 
The important practical bearing of this will be noted 
in the proper place. Another force may assist in de- 
livery, viz., gravity. The amount of force employed 
in truly normal labor is not great. 

The following, from J. Matthews Duncan (Re- 
searches, p. 319), will suffice to illustrate this point : 
" If we regard the figure of four pounds given by Pop- 
pel as equal to the power exerted in the easiest labor 
he has observed, or the corresponding figure of six 
pounds, according to my calculations, and keep in 
mind that the average weight of the adult foetus ex- 
ceeds either of these weights, we are led to the conclu- 
sion that in the easiest labors almost no resistance is 
encountered by the child ; that it glides into the world 
propelled by the smallest force capable of doing so ; 
that with the mother in a favorable position, the 



38 HOW TO USE THE FORCEPS. 

weight of the child is enough to bring it into the 
world — a result which many clinical facts at least ap- 
pear to confirm." The same author says also : " Hav- 
ing had extensive and varied experience in the use of 
forceps in difficult labors, and having also made some 
rough experiments with the dynamometer, to ascertain 
the power I have applied by the instrument, I regard 
M. Joulin's estimate of a hundred -weight, as the maxi- 
mum force of the parturient function, as too high. 
I do not deny that in very rare cases such a force 
may possibly be produced, but I am sure that it is 
nearer the truth to estimate the maximum expulsive 
power of labor (including the uterine contractions 
with the assistant expulsive efforts) as not exceed- 
ing eighty pounds." In this opinion I entirely 
agree, believing that the extreme efforts made in 
some cases with the forceps are due to a misappre- 
hension of the proper direction of force, rather than 
to any need for such an amount of force. 



SECTION III. 

THE BODY TO BE PROPELLED. 

The child for whose sake all this machinery is 
ordered is, when packed in the womb, of ovoid 
shape. At one end is the head, at the other the 
similarly ronnded breech. Like an egg, it is natural 
for it to pass through the pelvis endwise, with one 
end or the other in advance. As the head is freely 
movable upon the neck and capable of considerable 
extension, either the top of the head or the face may 
be in advance. The child may also attempt to enter 
the pelvis crosswise or transversely. We have then 
four distinct methods of entrance. The part in ad- 
vance at the beginning of labor is called the present- 
ing part, and the area of this part inclosed by the 
pelvic circumference is technically called thepresenta- 
tion. 

There are therefore four distinct presentations : 
I. of the top of the head, or vertex ; II. of the 
Face ; III. of the Breech, and IV. Transverse. 

The vertex presents in at least ninety per cent. 
of all labors and is evidently the natural presentation 
and the one for which the pelvis is specially de- 



40 HOW TO USE THE FORCEPS. 

signed. I shall, therefore, confine my remarks to 
this presentation, with a brief account of the second, 
since the others are neither strictly normal nor suited 
for the application of the forceps. Let us first re- 
fresh our memories with some topographical anatomy. 
Upon the top of the foetal cranium appears a suture, 
extending directly antero-posteriorly between the pa- 
rietal bones, called the sagittal suture. At its pos- 
terior limit is a triangular membranous interval call- 
ed the posterior fontanelle or bregma. At its anterior 
limit is a similar quadrilateral interval called the an- 
terior fontanelle. From the posterior fontanelle a 
suture extends on either side, joining the occipital to 
the parietal bones of either side, the two being col- 
lectively called the lambdoidal suture. From the 
anterior fontanelle a suture extends in front which is 
practically a continuation of the sagittal, called the 
M-frontal suture. At right angles to it proceed from 
each side of the anterior fontanelle, sutures joining 
the anterior border of the parietal to the frontal 
bone, which are together known as the coronal su- 
ture. These fontanelles and sutures are of variable 
size, being sometimes large and distinctly recogniza- 
ble, in other cases small and indistinct. They are 
also more or less obscured by the covering of the hairy 
scalp. 

During labor the sutures themselves are not so 
apt to be felt as the overlapping edge of bone which 
results from their approximation. Between the 



THE BODY TO BE PKOPELLED. 41 

limbs of the lambdoidal suture, an inch or a trifle 
more from the posterior fontanelle, is the occipital 
protuberance, a prominent and useful landmark in 
ascertaining the position of the head at times. Still 
more useful are the parietal protuberances situated 
nearly in the centre of each parietal bone. The 
frontal eminences similarly situated in the frontal 
bones are hardly to be felt except in face presenta- 
tions or during the perineal stage of labor, and are 
not usually of diagnostic importance. The ears are 
scarcely ever within reach, still less the mastoid 
prominences. Not infrequently the small fonta- 
nelles at the postero-inferior angles of the parietal 
bones are within reach and are to be recognized by 
the extension into them of the lambdoidal suture. 
Certain planes and diameters are important for pur- 
poses of description. When the head is placed in a 
horizontal position quoad the body in the erect pos- 
ture, a plane drawn transversely through the occipi- 
tal and parietal protuberances will present an ellip- 
tical outline as already delineated in Fig. 6. This 
plane may be called, from its long diameter, the oc- 
cipitofrontal, the latter line extending from the oc- 
cipital protuberance to a point, in the bi-frontal su- 
ture. The transverse diameter is drawn from one 
parietal protuberance to the other, and is called the 
ti-parietal. It will be observed that this outline is 
not a perfect ellipse, the transverse diameter being 
behind the centre, though this irregularity is less 



42 HOW TO USE THE FORCEPS. 

marked in the living head than in the dried skull. 
The occipitofrontal diameter measures on an average 
a little more than four inches in length, the bi-pari- 
etal about three and a half inches. 

If the head is partially flexed, a similar trans- 
verse plane passing through the parietal protuber- 
ances will extend through the occipital ridge, or nape 
of the neck, and the apex of the forehead, and may 
be called the plane of demi-flexion. Its outline will 
be almost exactly elliptical ; the transverse diameter 
being the same as in the preceding plane, viz., the 
bi-parietal, and its long diameter, the cervico-frontal, 
will be a little less than four inches. If the head is 
completely flexed, as when the chin rests upon the 
breast, a similar plane drawn through the parietal 
protuberances will pass through nearly the same 
point posteriorly as in the last plane, viz., the nape 
of the neck a little below the occipital ridge ; and its 
anterior limit will be in the posterior margin of the 
anterior fontanelle. Its outline will be nearly circu- 
lar, for while the transverse diameter is still the bi- 
parietal, its long diameter, the cervico-bregmatic, is 
also three and a half inches long. This plane may 
be called the plane of complete flexion. Its circular 
outline is an important fact to bear in mind. 

The conclusion is now apparent that flexion of 
the head reduces the outline which it presents to the 
pelvic passages. It is of interest to note the relative 
position of the fontanelles during these changes. 



THE BODY TO BE PKOPELLED. 43 

When the occipito -frontal plane is horizontal the an- 
terior fontanelle appears nearly in the centre of the 
elliptical area above the plane, while the posterior 
fontanelle is very near its posterior margin. When 
the head is in demi-flexion the fontanelles appear 
very nearly in the foci of the ellipse, and in complete 
flexion the posterior fontanelle occupies the centre 
of the circular area presented, while its fellow has 
disappeared from view in front. 

The outline of the foetal head is still further capa- 
ble of being diminished by the overlapping of the 
parietal bones, either by compression due to the 
small size of the pelvic canal, or artificially by the 
forceps. The bi-parietal diameter can be lessened 
from a half inch to a full inch by such compression. 
Not only can these diameters be compressed and 
shortened by these agencies, but the entire shape of 
the head may be changed by a process of moulding 
during the process of expulsion. 

The face of the child offers little to detain us at 
this point. It is also of rather elliptical outline, 
having a long diameter, the fronto-mental, which ex- 
tends from the chin to the top of the forehead ; and 
a transverse diameter, the bi-malar, which extends 
from one malar bone to the other. But these are so 
much smaller than the diameters which lie behind 
them in the head, that the face evidently offers no 
difficulties per se in delivery. The real difficulties 
are due to the manner in which the bulkier posterior 



44 HOW TO USE THE FOECEPS. 

portion of the head and the body are made to enter 
the pelvis when the face presents, and this can be 
better described in connection with the mechanism 
of labor in this presentation. 

The hody of the child exhibits upon transverse 
section an elliptical outline in its entire extent, and 
especially at the level of the shoulders and breech. 
As has already been noted, the long diameters of 
such sections are at right angles to the long diam- 
eters of similar sections of the head, and from the fact 
that the foramen magnum is situated behind the 
centre of the head, the body tends to follow the head 
a little behind the central axis of the head. 



SECTION IV. 

THE MECHANISM OF DELIVERY. 

Since there is an evident correspondence between 
the pelvic canals and the head in their outline, it is 
a natural inference that the occipito-frontal plane of 
the head may enter either the right or left canal, and 
in two ways : with its occipital extremity either in 
front or behind. Clinical observation is usually in 
advance of theoretical knowledge, as is conspicuously 
shown by the fact that all recent writers agree in ad- 
mitting but four positions of the vertex. And yet, 
while the pelvic brim is considered as having an " ir- 
regularly oval outline," there is no obvious objec- 
tion to the eight positions of the earlier authorities, 
or indeed to any number whatever. It is only when 
we find that it is of singularly regular outline, by an- 
alyzing it, that we are compelled to see a theoretical 
reason for the already clinically observed fact. 

I. The Vortex. 

The nomenclature of these positions is founded 
on the position of the occiput, which will be situated 
on one side or the other and in front or behind. 
They are as follows : 



46 HOW TO USE THE FORCEPS. 

1. Left occipito-anterior. 

2. Eight occipito-anterior. 

3. Right occipito-posterior. 

4. Left occipito-posterior. 

1. The First or Left Occipito-Anterior Po- 
sition (L. 0. A.) is the most frequent, occurring in 
at least seventy per cent, of all positions of the ver- 
tex. The reasons for its prevalence are to be found 
in several combined causes. The folded-up attitude 
of the child in utero requires that its back shall be 
turned towards the mother's front. The prominence 
of the vertebral column and more esjDecially the sa- 
cral promontory, will determine the position of the 
occiput on one side or other of the median line. 
Since the long axis of the child is correspondent 
with that of the uterus, its head is placed directly 
over the initial plane of the right canal, owing to the 
usual right obliquity of the uterus. Also the right 
caual is actually a little larger than the left, and the 
latter contains under the left sacro-iliac arch the rec- 
tum, which still further diminishes its size. This is 
therefore the most natural and favorable of all the 
positions. 

At the beginning of labor the head in this posi- 
tion is placed with its occipito-frontal plane coinci- 
dent with the initial plane of the right canal. The 
occipital protuberance is opposite a point in front of 
the left acetabulum ; the bi -frontal suture is in front 



THE MECHANISM OF DELIVERY. 47 

of the right sacro-iliac symphysis, and the right par- 
ietal protuberance is opposite a point over the right 
obturator foramen towards its inner edge. The left 
parietal protuberance is not opposed to any point of 
the pelvic circumference, but is in the free space in 
front of the left sacro-iliac symphysis. The occipito- 
frontal diameter is therefore coincident with the 
right oblique diameter of the pelvis. The head is 
obliquely situated with reference to the plane of the 
conjugate diameter, one side of the head being below 
and the other above that level. This fact was first 
noticed by Naegele, but stated too generally, since 
this obliquity frequently and indeed usually disap- 
pears in the succeeding stages. For as soon as the 
uterine efforts become at all effective, the head un- 
dergoes a compound movement by reason of which 
its synclitism with the initial plane of the right canal 
disappears, and therefore its obliquity to the plane of 
the conjugate diameter, while another head plane 
than the occipitofrontal is made to engage by means 
of flexion. The cause of this movement is to be 
found principally in the unequal resistance offered by 
the pelvic walls. The right parietal protuberance is 
directly applied to the anterior pelvic margin, while 
the left is entirely free, and the same may be said of 
the entire right and left sides of the head, the protu- 
berances being cited merely as the more prominent 
parts. If the size of the head and the calibre of the 
right canal are at all equal and the fit is tight, the 



4:8 HOW TO USE THE FOKCEPS. 

right side of the head will meet with considerable 
resistance to its onward motion communicated from 
the uterine forces, and will, therefore, be arrested, 
while the left side, being untrammelled, will descend. 
There will result a lateral flexion of the head, which 
will bring the occipitofrontal plane synclitic with 
the plane of the conjugate diameter. 

If the abdominal muscles are called into action at 
this time, they will by their compression tend to 
force the uterus backwards and so deflect its axis as 
to still further impel the head against the anterior 
pelvic walls, which will also assist in bringiDg about 
this lateral flexion and the resultant synclitism. 
This synclitism is in reality an obliquity of the foetal 
planes to the transverse planes of the right canal, 
and continues throughout the further progress of 
the head, being indeed necessary when the head has 
reached the inferior strait. Before that point it does 
not invariably occur. The relative size of the head 
may be small, and it may continue in exact relations 
with the successive planes of the right canal through- 
out, as was practically the teaching of Naegele. But 
inasmuch as the head is usually large enough to offer 
an appreciable amount of resistance, the synclitism 
of the presenting plane of the head with the artificial 
planes of the pelvic cavity is the rule rather than the 
exception. This has led Cazeaux, Hodge, Leish- 
mann, and others to entirely combat the obliquity of 
the head at any time, which is an error in the oppo- 



THE MECHANISM OF DELIVERY. 49 

site direction, since it must originally exist from the 
manner in which the head enters the inlet. 

A similar cause to that which determines the lat- 
eral flexion of the head brings about at the same time 
flexion proper, or the movement of the chin towards 
the breast. Although the right oblique diameter 
with which the occipito-frontal is coincident is five 
inches long in the bony pelvis, the soft parts so di- 
minish the size of the canal that some lessening of 
the head outline, especially in its length, is usually 
necessary. The head may be regarded as a lever at- 
tached to the vertebral column as a fulcrum. The 
resistance which it encounters causes the anterior 
part of the head, which is the long arm of the lever, to 
be flexed towards the chest. Also, the occipital end 
of the head is in the anterior and roomy part of the 
pelvis, and thus more free to move than the frontal 
end, which is cramped by the narrower dimensions of 
the right sacro-iliac arch. 

This flexion continues until the head presents an 
outline small enough to pass readily, which usually 
happens when the plane of demi-flexion has become 
coincident with the plane of the conjugate diameter, 
or, to speak more accurately with a plane parallel to 
the latter, but a little lower in the pelvis. If the 
plane of demi-flexion presents too large a circumfer- 
ence, flexion continues until complete. If then there 
still remains any disproportion between the head and 
pelvis, the force is exerted upon all the diameters of 



50 HOW TO USE THE FORCEPS. 

the head, which is diminished in size by a general 
compression, From this results what is known as 
the moulding of the head, which so rearranges its 
shape that its original outlines are entirely changed 
and it becomes cylindrical. This, if successful, is 
continued until the diameters of the head correspond 
to those of the pelvic canal. I believe that this head- 
moulding often occurs at an earlier stage from a fail- 
ure of the head to properly undergo flexion, and 
that a thoroughly flexed head is rarely in need of any 
further diminution of its outline. Ordinarily the 
plane of demi-flexion will have a sufficiently small 
circumference, and the head is then ready to descend. 
The flexion of the head may and generally does 
occur before the os uteri is fully dilated. When this 
is completely effected the head at once descends with 
the plane of demi-flexion constantly synclitic with 
the successive artificial planes of the pelvic cavity. 
As it descends, it simultaneously rotates upon its axis, 
the occipital protuberance coming nearer and nearer 
to the median line ia front and the bi-frontal suture 
similarly approaching the median line behind. The 
course of the head is at first downwards, backwards, 
and inwards, following spirally the course of the axis 
of the right canal. The backward direction is soon 
changed to a forward one as it descends, but is im- 
portant while it lasts. Mechanically speaking, the 
uterine force is reflected from the pelvic walls so as 
to guide the head and induce this result. All parts 



THE MECHANISM OF DELIVERY. 51 

of the pelvic wall share in guiding the head, but the 
right ilio-sciatic line is especially effective. The 
right parietal protuberance is constantly in advance 
of this line, which has therefore a similar action 
to the rifling in a gun-barrel. The left pari- 
etal protuberance is remote from the left ilio- 
sciatic line, and crosses it during the movement 
of rotation before it is brought into very close rela- 
tions with it. The rotation of the head ceases when 
it reaches the inferior strait, with the parietal protu- 
berances in front of the ischial spines and its antero- 
posterior diameter in the median line, the plane of 
demi-flexion being completely coincident with the 
plane of the outlet. The ischial spines, which are 
the continuation of the ilio-sciatic lines, are usually 
more projecting than any other part of the latter. 
The inferior strait is therefore well named, being the 
narrowest part of the pelvis as well as the end of the 
double tube. 

A slight delay is apt to occur here, during which 
the movement of flexion is continued, if necessary, 
until the plane of complete flexion becomes coinci- 
dent with the plane of the outlet, after which the 
propulsion of the head is resumed. The subsequent 
course of the head is through the single tube formed 
by the soft parts, and might with propriety be set 
apart as a distinct stage of labor — the perineal stage 
— since a new force is here called into operation. 

Before describing it, I will call attention to a few 



52 HOW TO USE THE FOKCEPS. 

points in which the foregoing account differs from 
the received teaching upon this subject. Hodge, 
whose exposition of the mechanism of labor is the 
most complete extant, states* that the central por- 
tion of the child's head describes in its descent the 
axis of the general pelvic cavity. This axis extends 
centrally through the pelvis downwards and back- 
wards (afterwards forward), following the curve of 
the sacrum. The axis of the right canal, in which 
it is here asserted that the centre of the child's head 
moves, extends spirally downwards, backwards, and 
inwards. If a piece of card-board be cut out, of el- 
liptical outline, similar to the outline of the occipito- 
frontal plane, or the plane of demi-nexion, and ap- 
plied to the pelvic inlet, so that its long diameter 
corresponds to the oblique diameter as already de- 
scribed, the centre of the ellipse will be found to be 
at quite an appreciable distance to the right of the 
median line,. But if the ellipse is placed in the pel- 
vic outlet in the same manner as the head occupies it 
during labor, its long diameter, and therefore its cen- 
tre, will be exactly in the median line. Therefore in 
moving from the superior to the inferior strait the 
centre of the head moves towards the median line, or 
inwards, as does the axis of the right canal. 

As a necessary concomitant or preliminary to this 
inaccuracy of the existing doctrine, some vagueness 
of expression concerning the true position of the 
* System, p. 30. 



THE MECHANISM OF DELIVERY. 53 

head at the inlet will be found, for if the latter- 
had been accurately noted, it would at once have 
been manifest that the head does not occupy the in- 
let centrally. The same author states.* " In the 
first position of the vertex, after flexion has been per- 
fected, it is strictly correct to say that the nape of 
the neck, or sub-occipital region, is opposite the left 
acetabulum, and the anterior fontanelle to the right 
sacro-iliac symphysis ; while the right parietal pro- 
tuberance is to the right acetabulum and the left to 
the left sacro-iliac symphysis.'' These four points, 
the parietal protuberances, occipital protuberance, 
and anterior fontanelle, are about equidistant. A 
head which has its occipital protuberance opposite 
one acetabulum and its right parietal protuberance 
opposite the other acetabulum, would, if finished 
upon the same magnificent scale, be difficult to place 
in the human pelvis. The correct jDOsition is stated 
on pages 46—1:7. 

The importance of accurate discrimination in 
these points will be more apparent in connection with 
the application of the forceps. It is sufficient to 
note here that the head, not being placed centrally, 
leaves quite a large free space in front of the left sa- 
cro-iliac symphysis. 

As the head passes through the inferior strait, and 
even a little before, it begins to encounter the re- 
sistance of the pelvic floor, against which it is pro- 
* Op. Cit, p. 148. 



54 HOW TO USE THE FORCEPS. 

pelled. This brings to bear upon it the force de- 
scribed at page 37. Assuming that complete flexion 
has taken place at the outlet, as is customary, the 
plane of complete flexion is coincident with that of 
the outlet. As the head is propelled forward in the 
line of the resultant of the two forces, the plane of 
complete flexion continues to maintain its coincidence 
with the successive transverse planes of the parturi- 
ent passage. The flexion of the head is, however, 
not kept up, but extension occurs progressively dur- 
ing the remainder of its course. 

The movement of extension is readily seen to be 
somewhat different in its results from the mere re- 
versal of flexion. This is due to the different cir- 
cumstances under which the movements take place. 
Flexion at the inlet resulted in bringing new planes 
of the head in relation with the pelvic planes, and 
the same is true throughout the pelvis. But the ex- 
tension which occurs after the passage of the inferior 
strait has no such displacing effect, the cervico-breg- 
matic diameter continuing to coincide with the an- 
teroposterior diameter of each successive plane of 
the passage. Extension occurs because of the great 
curvature of the canal at this point, which takes a di- 
rection almost opposite to that of the bony canal. 
This necessitates a bending of the projectile upon it- 
self, since the body cannot at once be dragged down 
with the head. This movement keeps the smallest 
attainable outline of the head in relation with the 



THE MECHANISM OF DELIVEKY. 55 

vaginal tube. The sub-occipital region remains un- 
der the sub-pubic arch, while the forehead and face 
sweep over the perineum. The perineum becomes 
greatly distended and changes its shape. It is, as be- 
fore noted, wedge-shaped or triangular upon section, 
the apex of the triangle being at the verge of the 
anus. As the head glides upon and over it the apex 
of the triangle moves forward and a large portion of 
the anterior wall of the rectum is added to the peri- 
neal surface. 

It is very necessary to remember this forward 
motion of the perineum in any attempts to assist the 
natural mechanism. As the head escapes from the 
vulvar orifice the perineal tissues retract to nearly their 
original condition, chiefly by reason of their inherent 
elasticity, aided somewhat by the action of the trans- 
verse muscles of the perineum. The vulva will then 
embrace the child's neck, while the head, released 
from the tube, is again flexed. So far as the forceps 
are concerned, we might here suspend the account of 
the mechanism of labor, but for the sake of com- 
pleteness and for the light which may be thrown on 
the foregoing stages, we will continue it. At the 
moment of birth the head was propelled almost ver- 
tically upwards (the woman being upon her back), 
while the body remains behind and in a general way 
at right angles to the long diameter of the foetal 
head. Hence the flexion or dropping of the chin 
when the head is born. A lateral movement is also 



56 HOW TO USE THE FORCEPS. 

described, called restitution, in which the head turns 
obliquely after birth, with the occiput in front and 
to the left, as when at the inlet. 

This is of little importance, nor does it always oc- 
cur, since it depends upon the manner in which 
the body conforms to the mechanism by which the 
head was delivered. As the head passes the inferior 
strait the shoulders enter the pelvis if the neck is of 
its ordinary length. As already noted, their proper 
method of entrance is with their long or bis-acromial 
diameter coincident with the left oblique diameter of 
the inlet, and their elliptical outline in connection 
with the beginning of the left canal. This is the 
natural provision ; after which they descend in that 
canal, rotating in the opposite direction to that which 
the head followed. After the delivery of the head 
they arrive at the inferior strait with their long di- 
ameter in the median line and the right shoulder in 
front. Circumstances cause this mechanism to be 
often varied from. The mobility of the neck and its 
varying length do not render it absolutely necessary 
that the shoulders should follow the rotatory move- 
ments of the head or be affected by them. Per con- 
tra, the shoulders may be prematurely and unduly 
influenced by the head rotation. Hence, when the 
head has assumed its directly antero-posterior posi- 
tion at the inferior strait the shoulders may have 
been compelled to engage in the inlet with their long 
diameter directly transverse and thus out of relation 



THE MECHANISM OP DELIVERY. 57 

with either canal. Since they have not the solid and 
comparatively unyielding organization of the head, 
there is less need for their conforming strictly to the 
requirements of the passage, and they may, under 
these circumstances, be dragged or pushed through 
the pelvis, without any reference to the separate ca- 
nals, until they reach the inferior strait. Here the 
bis-acromial diameter will prove too long, under any 
ordinary compression, to pass through the strait in 
coincidence with the transverse diameter of the 
strait, and the shoulders must rotate as they would 
have if they had started right in the first place. It 
will be to a great extent a matter of accident whether 
they rotate so as to bring the right shoulder in ad- 
vance, as it would have been after descent in the left 
canal, or the left shoulder, as would occur after the 
descent in the right canal. 

But if the former occurs, the back of the child 
being directed to the left side, the free head will 
have its occiput turned towards the left, and in the 
latter case, the child's back being to the right the oc- 
ciput will also turn towards the right. It is not, 
therefore, proper to say that observance of the direc- 
tion in which the movement of restitution is made 
will show us what the original position of the head 
at the inlet must have been. Very generally the 
shoulders observe the natural mechanism and the bis- 
acromial diameter becomes coincident with the left 
oblique diameter of the inlet with the right shoulder 



58 HOW TO USE THE FORCEPS. 

in advance. If the outline of the shoulders is not un- 
duly large this relative position of shoulder and pel- 
Tic outline is maintained until complete delivery. A 
plane passing transversely through the shoulders con- 
tinues to be syn clitic with the successive planes of 
the parturient passage until at the vulvar outlet it is 
expelled. The right shoulder remains stationary at 
the sub-pubic arch, while the left shoulder sweeps 
over the perineum. Where the shoulders are a little 
larger than common, the plane just mentioned be- 
comes oblique from the moulding of the shoulders, so 
that the left or posterior shoulder is crowded in ad- 
vance of the right shoulder and maintains this posi- 
tion throughout, arriving at and passing through the 
vulvar outlet before the right shoulder instead of 
simultaneously escaping. Or it may happen that in 
the moulding process the right or anterior shoulder 
obtains precedence. 

Opinions differ as to which of the two is the nat- 
ural course, and probably from a want of sufficiently 
numerous and accurate observations. Where it is 
desirable to have exact knowledge, as when we at- 
tempt to aid the process artificially, there are reasons 
for preferring the prior delivery of the left or pos- 
terior shoulder. Such an occasion often presents it- 
self. The delivery of the head is frequently followed 
by a more or less temporary cessation of uterine con- 
tractions. Under such circumstances the child may 
be in danger of asphyxia from pressure upon the 



THE MECHANISM OF DELIVEKY. 59 

funis, if the body is large or the funis wrapped around 
the neck, so that an immediate delivery of the shoul- 
ders by the physician is to be recommended. If the 
posterior shoulder is made to keep in advance, a 
shorter diameter than the bis-acromial is permitted 
to coincide with the antero-posterior diameter of the 
tube, and a smaller outline being presented the peri- 
neum is less distended. This is true whichever 
shoulder is in advance, but the posterior is usually 
more accessible to the finger and more easily drawn 
down. Also, if the posterior shoulder is first deliv- 
ered, the sharp projection of the shoulder is made to 
pass over the perineum before the full bulk of the 
body becomes engaged with it, and is therefore less 
likely to make a rent in that structure, as so often 
happens. The rest of the body follows the shoulders 
at once, being too small as a rule to bear any definite 
relation to the pelvis. Occasionally the breech is 
large enough to fit quite closely when, being of simi- 
lar outline to the shoulders, it observes the same 
mechanism. 

To recapitulate. The head in the first position 
of the vertex enters the pelvis with its occipito- 
frontal plane coincident with the initial plane of the 
right canal, and therefore oblique to the plane of the 
conjugate diameter. Its first movement is a com- 
pound lateral and forward flexion, which brings the 
plane of demi-flexion in coincidence, not with the ini- 
tial plane of the right canal, but with a plane paral- 



60 HOW TO USE THE FORCEPS. 

lei to that of the conjugate diameter, while at the 
same time its outline is diminished. Its second 
movement is rotation during descent, the former 
bringing the occiput gradually in front while the 
centre of the head moves spirally in the axis of the 
right canal. At the inferior strait the flexion is, if 
necessary, continued until, if not before, the plane 
of complete flexion is made to coincide with the 
plane of the outlet, the occipital end being directly 
in front. This relative position continues while the 
head undergoes a third movement, of extension, dur- 
ing the rest of its course, being expelled from the 
vulvar outlet in a state of complete extension, but 
with the cervico-bregmatic diameter still at right 
angles to the axis of the tube. Next the shoulders, 
having engaged in the left canal, rotate as they de- 
scend ; arrive at the inferior strait with the right 
shoulder in front, which is detained under the pubes 
until the posterior shoulder sweeps over the perineum, 
and so out, when the rest of the child promptly 
emerges. During the perineal stage the head moves 
in a direction almost completely the reverse of its di- 
rection at starting. 

This mechanism may be clinically verified in many 
cases. At the outset of labor, when the os uteri is 
but partially dilated, and the bag of waters uni- 
formed, and the head resting loosely at the inlet, a 
careful examination will show it to be situated as 
follows : The posterior fontanelle will be almost in- 



THE MECHANISM OF DELIVERY. 61 

accessible, being at or above the ilio-pectineal line, 
opposite a point in front of the left acetabulum. 
The right branch of the lambdoidal suture will also 
be difficult to reach, extending from the posterior 
fontanelle in a direction nearly parallel to the top of 
the os pubis, and ending in the small fontanelle at 
the postero-inferior angle of the parietal bone. If 
the head is still oblique this fontanelle can be felt, 
and if the head is not unduly large even the ear may 
also be detected in its neighborhood. But if the con- 
tractions of the uterus have already forced the head 
into a parallelism with the plane of the conjugate 
diameter they will be entirely out of reach of an or- 
dinary examination at this stage of the labor. The 
sagittal suture will be felt extending first downwards 
from the posterior fontanelle and then obliquely 
backwards towards the right sacro-iliac symphysis, 
thus having the same general trend as the long diam- 
eter of the initial plane of the right canal. The 
right parietal protuberance will be felt at or below 
the level of the pectineal line opposite a point to the 
right of the pubic spine and in a line which, verti- 
cally drawn, would pass through the obturator fora- 
men near its inner edge. So far as the finger can 
determine, the central part of the presentation is mid- 
way between the parietal protuberance and the sagit- 
tal suture or thereabouts. And yet from the descrip- 
tion it is evident that the centre of the presenting 
part must lie in the sagittal suture and not to one 



62 HOW TO USE THE FORCEPS. 

side. This apparent discrepancy is due to the curva- 
ture of the pelvis, so that the horizon of examina- 
tion, as we may call the limit of the area within 
reach of the fingers, differs from the horizon actually 
present at the brim. The arguments as to the posi- 
tion of the head, based upon the location of the caput 
succedaneum which forms during the arrest of the 
head at the inlet, are of doubtful value. 

Carefully observed and recorded instances are 
wanting, as is admitted by Matthews Duncan ; and, 
until we have more exact facts, reasoning upon theo- 
retical principles is fallacious. If I might venture a 
hypothesis, it would be that the caput succedaneum 
forms in front of the centre of the presentation for 
reasons similar to those which cause the anterior lip 
of the womb to become oedematous in preference to 
any other part of the cervical rim. 

As soon as synclitism takes place, the right branch 
of the lambdoidal suture ascends above the os pubis, 
becoming inaccessible until flexion and the descent of 
the occiput bring it again within reach. This may 
happen synchronously, in which case it does not 
ascend, but in either case its direction will be changed 
and it will no longer be parallel with the top of the 
os pubis. The posterior fontanelle becomes more and 
more accessible with each degree of flexion. As rota- 
tion and descent proceed it becomes more centrally 
situated, being nearer the median line as well as lower 
in the pelvis. The left branch of the lambdoidal suture 



THE MECHANISM OF DELIVERY. 63 

becomes apparent as soon as the head begins to rotate, 
and even before, to some extent, when the head is 
well flexed. The right parietal protuberance recedes 
almost directly backwards and to the right side, and 
when the head has reached the inferior strait each 
protuberance may be felt with some difficulty ex- 
actly opposite to each other, while the posterior fon- 
tanelle occupies the median line ; in the centre, if 
the head is completely flexed, a little above or in 
front, if flexion is less complete. At this time the 
sagittal suture extends directly backwards, the two 
branches of the lambdoidal suture extending from it 
above like the arms of the letter Y. This adjust- 
ment of parts to the pelvic tube is continued 
throughout the remainder of the labor. The occipi- 
tal protuberance, being in advance of the fontanelle, 
appears first at the vulva, and as the latter orifice is 
enlarged the rest of the presentation is gradually 
uncovered until the parietal protuberances are exposed, 
when the head slips out. 

The compound flexion, rotation, and extension 
are easily observed and verified in the succession of 
events, but the inward motion of the head is difficult 
if not impossible to appreciate by direct observation. 
The distance travelled is short, especially in front, 
where our observation is mainly directed. The occi- 
put also rotates in an opposite direction to the course 
which the centre of the head travels, which further 
obscures the problem. But although it cannot be 



64 HOW TO USE THE FORCEPS. 

directly traced with the finger, it is evident enough 
from the conformation of the pelvis, and receives fur- 
ther corroborative proof during the use of the for- 
ceps. 

Variations from this mechanism may and do occa- 
sionally occur, and are of some practical importance. 
They may be said to consist in either an exaggeration 
or deficiency of some of the natural processes. Thus, 
a want of sufficient flexion at the inlet may cause a 
long delay at the inferior strait, while this defect is 
being remedied, or the head may fail to engage at all, 
for the same reason. Flexion may be too great, or 
rather extension may fail to occur at the proper 
point, causing delay in the perineal stage. A misap- 
plication of the propulsive force may interfere with 
rotation, or the head, being unusually small, may de- 
scend obliquely throughout, and even be born in that 
manner. Other variations arise from a disproportion 
between the head and pelvis, from a want of elastic 
force in the perineum, or from other organic causes. 
But where the head and pelvis are each normal and 
proportionate there is seldom any deviation from 
the above-described process. 

The time occupied in the movement of the head 
through the pelvis varies in the same individual even, 
from different circumstances, formally, in multi- 
parae, ten or fifteen minutes suffice, after full dilata- 
tion of the os, to complete the delivery of the child. 
In primiparse, from a half hour to an hour and a 



THE MECHANISE OF DELIVERY. 65 

half is usually required, one half of which time is 
consumed in the perineal stage. "Where the propul- 
sive force is of ordinary strength these limits are 
rarely exceeded, and if they should be in any case, 
the cause for the delay should be carefully deter- 
mined and if possible removed. The amount of de- 
lay which should be regarded as demanding instru- 
mental interference will be discussed in a subsequent 
chapter. 

2. The Second or Eight Occtpito-Anterior 
Position (R. 0. AJ] of the vertex is less frequent 
than the first, for reasons already assigned, occurring 
perhaps in teu per cent, of all positions of the vertex. 
It is possible that it is frequently only a stage of the 
third position, as will be mentioned under that head, 
which was the view taken by X aegele in all cases. It 
theoretically offers more difficulties and is more apt 
to need assistance than the first position, from the 
comparative smallness of the left canal and the en- 
croachment of the rectum. So far as my own obser- 
vations extend this is perceptibly true, but the dif- 
ference is not great. It follows precisely the same 
mechanism as the first, with its direction of motion 
reversed, and the description of the former mechan- 
ism will answer as well for it, substituting through- 
out the account ''-'right " for "left " wherever needed. 
In this position the occipito-frontal plan coincides 
with the initial plane of the left canal at the begin- 
ning of labor. The head then descends in that 



66 HCTW TO USE THE forceps. 

canal, its centre following the axis of the left canal 
until the point of fusion at the inferior strait is 
reached, when it proceeds in the same course and 
manner as the first does, during the remainder of its 
course. Wnere there is any difference in the mech- 
anism, it usually consists in a longer delay at the 
inlet at the beginning until flexion is absolutely com- 
plete. The shoulders descend in the right canal as a 
rule, and are more apt to observe a uniform mechan- 
ism than in the first position because they are nat- 
urally placed in the more roomy canal. These two 
occipito-anterior positions are the only ones in which 
labor can strictly be called normal. The pelvis is 
evidently constructed with a special design for such 
a mechanism, and although other positions and 
presentations have often an uncomplicated and easy 
termination, they all have some elements which are 
apt to give trouble and which show that they are ex- 
ceptional. 

3. Ln" the Thied or Eight Occipito-Posterior 
Position of the Vertex (R. 0. P.) the head occu- 
pies the right canal as in the first position, but with 
its occipital end reversed. It is more frequent than 
the second position, for some of the same reasons 
which determine the prevalence of the first, and oc- 
curs in about seventeen per cent, of all positions of 
the vertex. At first sight there appears to be no 
reason why the same mechanism will not answer for 
both anterior and posterior positions. If the calibre 



THE MECHANISM OF DELIVERY. 67 

of the tube is elliptical in outline it might be sup- 
posed that the similarly elliptical outline of the head 
might descend in whichever way the ends might 
point, whether in front or behind. 

For several reasons, however, the mechanism is 
quite different. The principal cause of this is to be 
found in the manner in which the head is joined to 
the body, the point of attachment being towards the 
occipital end, instead of in the centre of the head. 
This causes the propulsive force, which is trans- 
mitted through the vertebral column, to act in a line 
too far back in the pelvis. The parietal protuber- 
ances are also placed on the wrong side of the ilio- 
sciatic line. To which we may add that the occipital 
end of the head is, if not larger, at least more firm and 
resistant than the anterior. The effect of these con- 
ditions will be best understood by observing the 
course of the head. 

Four methods of delivery are possible in this posi- 
tion ; and yet, in spite of this variety, nature is often 
incompetent to complete the task. The method 
usually regarded as the most common one is as fol- 
lows : 

a, First, Mechanism. — At the beginning of labor 
the head is placed with the occipital protuberance 
opposite the right sacro-iliac symphysis ; the anterior 
f ontanelle opposite a point in front of the left acetabu- 
lum ; the left parietal protuberance is in front of the 
beginning of the right ilio-ischiatic line, and in close 



68 HOW TO USE THE FORCEPS. 

relation with it ; the right protuberance is just to 
the left of the sacral promontory. The occipito- 
frontal plane is coincident with the initial plane of 
the right canal, so that the head is obliquely placed 
as in the first position, but in the contrary direction, 
the left side of the head being lower than the right. 
The first effect of the uterine contraction is, as be- 
fore, to remove this obliquity and bring the occipito- 
frontal plane into parallelism with the plane of the 
conjugate diameter. Flexion is also coincidently in- 
stituted, but with a modification of its effect. If the 
occipital extremity of the head impinges closely 
against the right sslgto- sciatic arch, which is usually 
the case, flexion has a tendency to bring the verte- 
bral column of the child still further backwards in 
the pelvis and to wedge the head in the chord of the 
arch — i.e., in the right sacro-cotyloid diameter (CD 
in Fig. 20). The bi-parietal diameter is too large to 
be so disposed of, and therefore the resistance of 
the ends of the arch, viz., the promontory and an 
opposite point in the right ileo-pectineal line, throw 
the head forward. Flexion has, in itself and apart 
from the direction of the force, a tendency to throw 
the bi-parietal diameter forward and nearer the cen- 
tral line, and this operates also to make the head 
clear the narrow space in which its occiput would 
otherwise be detained. 

If a comparison is m#de between the outline of 
the head and pelvis it becomes apparent that without 



THE MECHANISM OF DELIVERY. 69 

this forward movement of the head there would be a 
permanent arrest at this point, since the bi-parietal 
diameter would lie, not in the left oblique diameter 
as in the first position of the vertex, but in the chord 
of the ssLcro-sciatic arch, which is always smaller than 
this diameter. The disadvantage of having the pro- 
pulsive force transmitted so far back in the pelvis is 
therefore considerable. Flexion having continued 
until this difficulty is obviated, the head descends in 
the right canal with a spiral 
rotation in the axis of that 
canal, the occiput becoming 
more and more posteriorly 
situated, until it nears the 
inferior strait. At this level 
it encounters such an out- 
line as is represented in 
Fig. 18, in which A and B *™- 18. 

mark the position of the ischial spines, and the 
oblique line CD the bi-parietal diameter of the head. 
The arrows show the direction in which it is rotat- 
ing. Now, at either end of this diameter are the 
parietal protuberances, and to complete posterior 
rotation and bring the occiput fairly in the sacral 
concavity, the protuberances must ride over the 
ischial spines or the ilio-ischial lines just above them. 
This is not feasible if the proportions between the 
head and pelvis are at all close. Therefore, the bi- 
parietal diameter must beat a retreat and occupy the 




70 HOW TO USE THE FORCEPS. 

position it takes in the second position at this stage, 
where, from the fact that the ischial spines are back 
of the central meridian of the pelvis, only one of the 
protuberances has to cross the ilio-ischial line, and 
that not in a close relation. In other words, although 
the canals are nearly identical here, there must be 
a transfer of the head from the right to the left 
canal. 

Since an ellipse cannot be turned within its own 
circumference, flexion must persist until the circular 
outline of the cervico-bregmatic plane has been 
reached, and then it is possible for the head to rotate 
from the right to the left canal. In so doing, the 
previous motion is simply reversed and rotation con- 
tinued until the occiput is 

brought in front and the 
head placed precisely as in 
£_Z \ — ^ a right-occipito-anterior posi- 
tion of the vertex after it 
has reached the inferior strait. 
This is accomplished mainly 
by the action of the shoulders. 
Fig. 19. Tn e elliptical outline of the 

shoulders was found to have its long diameter at right 
angles with that of the head. If in Fig. 19 the long 
diameter of the shoulders, AB, is placed over the bi- 
parietal diameter, CD, where it actually falls, its ends 
would project decidedly beyond C and D ; therefore, 
in applying such an outline to that of the inlet, Fig. 





THE MECHANISM OF DELIVERY. 71 

20, the shoulders will be evidently seen to extend be- 
yond the limits of the chord of the arch CD. And 
if the bi-parietal diameter was too small to remain in 
that relation, much more will the shoulders be de- 
flected elsewhere. 

In the great majority 
of instances the shoul- 
ders will be thrown to 
the right of the verte- 
bral column, since the 
right shoulder will im- 
pinge upon the verte- 
bral Column just above a B, line in which the shoulders fall in 

, _ , anterior position, 

the promontory Of the c D, line in which the shoulders fall in 
m, posterior position. 

sacrum. Ihey are 

therefore forced to enter the right canal with the 
back of the child antero -laterally placed instead of 
entering the left canal, which at first sight appears 
more natural. This brings the long diameter of the 
shoulders parallel to the antero-posterior diameter of 
the head while the latter is rotating posteriorly 
about half way between the inlet and outlet, and the 
neck is thereby twisted through an arc of 90°. This 
involves tension of the neck, and therefore the devel- 
opment of an untwisting force, which becomes con- 
stantly greater, for as the head attempts to rotate 
posteriorly, the shoulders being stationary at the brim 
will cause it to be resisted, and as soon as the head 
offers a circular and turnable outline, the untwisting 



72 HOW TO TTSE THE FORCEPS. 

force, added to the uterine efforts, accomplishes an- 
terior rotation, and the head enters the inferior strait 
with the occiput in front. It is probable that the 
oblique direction in which the uterine force is trans- 
mitted tends to promote rotation at all times. This 
is at least worthy of investigation. A slight varia- 
tion of this mechanism is occasionally observed in 
which posterior rotation does not continue until so 
low a level as the inferior strait, but flexion is either 
completed at the brim or completed synchronously 
with descent, anterior rotation also occurring grad- 
ually throughout. By this commingling of the steps 
the head is already rotated anteriorly or nearly so, 
by the time the head arrives at the inferior strait. 

Z>, The second mechanism consists in anterior rota- 
tion of the occiput at the inlet and an immediate 
conversion into a second position (R. 0. A.), at that 
point. It is generally believed that the first mechan- 
ism is the most common, but, as already stated, Nae- 
gele attributed all second positions of the vertex to 
this second method. With existing data it is impos- 
sible either to prove or disprove the allegation, and 
hence we may properly classify the positions as when 
we first see them, otherwise this would be the most 
frequent method of delivery in this position, the E. 
0. A. being entirely discarded. Its occurrence is 
favored by the large size of the head and a delay in 
flexion. In such case, the disproportion will be too 
great to allow the occiput to descend at all while pos- 



THE MECHANISM OF DELIVERY. 73 

teriorly placed, and it is therefore forced anteriorly 
in the only direction in which it can enter. The po- 
sition of the shoulders has also much influence upon 
it. If the child, in titer o, is so placed that its back 
looks to the right side of the mother, it is obviously 
a matter of indifference whether the occiput is turn- 
ed in front or behind ; but if the child's back is 
turned directly forward the occiput must of necessity 
come forward also, sooner or later, if there is much 
resistance at the beginning of its descent. The for- 
ward turning of the body, when originally placed 
nearly in the antero-posterior line, may be due to 
the uterine contractions, voluntary movements of 
the foetus, or a change of position of the woman, 
which involves pressure of the abdominal muscles 
upon the child through the uterine walls. It is the 
most favorable mechanism and the one to be brought 
about artificially, if possible. After its accomplish- 
ment the head proceeds as in the second position. 

c, The third mechanism consists in continuous pos- 
terior rotation, the occiput remaining posterior 
throughout the whole delivery. Where there is a 
great want of correspondence between the head and 
pelvis, due to the smallness of the former or largeness 
of the latter, the head may descend with the occiput 
posteriorly or in any other way, like a shot in a mus- 
ket-barrel. But in cases where a more exact propor- 
tion exists, a definite and distinct mechanism is ob- 
served. The head descends in the right canal as in 



74 HOW TO USE THE FORCEPS. 

the first mechanism, until it reaches the level of the 
ischial spines when, instead of anterior rotation oc- 
curring, the occiput rotates posteriorly. This is ef- 
fected by great compression and moulding of the head, 
so as to diminish the prominence of the parietal pro- 
tuberances. If the shoulders are placed transversely 
at or above the inlet, with the back squarely to the 
mother's back, posterior rotation must occur or none 
at all. The head is therefore arrested and moulded 
by the propulsive force until its bi-parietal diameter 
is sufficiently reduced. Usually complete flexion 
first occurs with an abortive attempt at effecting the 
first mechanism. When the ilio-sciatic lines or the 
parietal protuberances are of average prominence 
this is a tedious performance, consuming much time, 
strength, and patience ; neither are the natural ef- 
forts always adequate. When posterior rotation is 
complete the head is placed in the outlet with the 
cervico-bregmatic plane coincident with the plane of 
the latter and the occiput directly posterior. The 
disadvantages of the position accumulate as it at- 
tempts to proceed. The manner in which the ver- 
tebral column is attached to the head causes the pro- 
pulsive force to be transmitted behind the centre of 
the head and pelvis alike. The greater the flexion, 
the nearer the foramen magnum is to the occipital 
end of the head, and hence the line of force trans- 
mitted by the vertebral column to the condyle on 
each side of the foramen is thrown backwards by 



THE MECHANISM OF DELIVERY. 75 

flexion. The head is therefore forced against the 
end of the sacrum, or at best against the base of the 
coccyx, and the secondary force originating in the pel- 
yic floor cannot so well reach the head to impel it 
forward. The uterine force must then be spent in 
moulding the head until it is long enough to reach to 
and be affected by the perineum. The occiput re- 
maining stationary the head is cylindrically moulded 
so that the cervico-bregmatic plane is thrown in ad- 
yance of the outlet and a new plane made to take its 
place, not by an extension of the head, but by its be- 
ing compressed into a longer shape. After a time, 
if the head is compressible, and the force holds out, 
the head becomes long enough to be acted on by 
the perineal force, and is then conducted to the vul- 
var outlet and expelled. Where from the small size 
of the head and body this moulding is unnecessary, 
the cervico-bregmatic plane continues to occupy the 
same position as in the case of the L. 0. A., but with 
the occiput behind, and is so expelled, the forehead 
gliding under the sub-pubic arch. The perineum is 
in more danger of laceration from this mechanism 
than from any other ; since the propulsive force is 
directed so far back upon it, that it may be said to 
attack it in the rear. The occiput is also more 
pointed than the forehead, and more apt to make a 
rent during its transit. This is, then, an unnatural 
mechanism, eveu when spontaneous, and is to be pre- 
vented if possible. 



76 HOW TO USE THE FORCEPS. 

d, A fourth termination exists, rarely witnessed, 
but which, may be taken advantage of in some cases to 
the great benefit of the perineum. In this the mech- 
anism is precisely the same as in the third method, 
until the head is completely beyond the inferior 
strait, and resting on the perineum with the anterior 
fontanelle within the lips of the vulva. At this 
point anterior rotation may take place, the head ro- 
tating around the axis of the cervico-bregmatic diam- 
eter, from left to right, until the sub-occipital region 
is brought under the symphysis pubis. It is then 
an occipitoanterior position, and is expelled as such. 
This was noticed to occur spontaneously by Cazeaux* 
in one instance, and in another I have brought it 
about by manipulation, f It likewise is probably due 
to the influence of the neck and shoulders. If the 
child's back is directed anteriorly, the untwisting 
force of the neck may be resisted while the head is 
in the bony pelvis, but whenever it has escaped from 
it into a tube which is dilatable in more than one 
direction, this force becomes irresistible, and whirls 
the head around with the occiput in front. Even 
when the shoulders descend with the back poste- 
riorly, the untwisting force may be considerable after 
they have advanced to any extent in the pelvis, 
though rarely enough to effect anterior rotation. 

* "Midwifery." Edition 1869, p. 367. 

f " American Journal of Medical Science," January, 1877. 



THE MECHANISM OF DELIVERY. 77 

Clinically, the third position of the vertex may be 
observed as follows : At the beginning of labor the 
anterior fontanelle, or its posterior edge, may be felt 
in front of the left acetabulum, or about in the same 
position as the posterior fontanelle occupies in the 
first position. It may usually, but not always, be 
distinguished from the latter by its large size and 
quadrilateral shape. The sagittal suture is found 
extending diagonally to the right in the same fashion 
as in the first position. There is also a suture ex- 
tending from the anterior fontanelle corresponding 
to the right branch of the lambdoidal suture, viz., 
the coronal, but it is more accessible at the begin- 
ning of labor, though also nearly parallel to the top 
of the os pubis. The left parietal protuberance is to 
be felt just in front of the right acetabulum, being 
much further back than (he light one is in the first 
position. The bi-frontal suture is sometimes regard- 
ed as a means of diagnosis in this position, since 
when it is felt we may know that there are four su- 
tures radiating from the fontanelle. It is scarcely 
ever to be felt, however, and not at all unless the 
head is abnormally extended, and the ear can, under 
ordinary circumstances, be felt with less difficulty. 
The horizon of examination is similarly limited as in 
the first position, the centre being at a point near 
the anterior end of the left parietal bone, where the 
caput succedaneum forms, if at all. 

The most important distinction between the first 



78 HOW TO USE THE FORCEPS. 

and third positions as regards diagnosis is in the ef- 
fects of flexion. In the first position the posterior 
fontanelle becomes more and more accessible during 
its progress and during rotation and descent, and 
finally occupies a central position. In the third, the 
anterior fontanelle, which has the same relative posi- 
tion, is raised by flexion, and while at the inlet re- 
cedes in direct proportion to its degree. If complete 
flexion occurs, the anterior fontanelle entirely disap- 
pears and the posterior fontanelle maybe felt behind 
and to the right of the centre of the horizon of exam- 
ination. During descent the anterior fontanelle is 
never centrally placed, even when in the median line 
after complete posterior rotation. If the head is small 
and flexion incomplete it may be felt in front during 
the whole of the third mechanism, but otherwise if 
the plane of complete flexion comes to be at right 
angles to the axis of the canal, the anterior fonta- 
nelle is not felt after the beginning of the labor until 
birth. 

4. The Foueth or Left Occipito-Posterior 
Position of the Vertex (L. 0. P.) bears the same 
relation to the third that the second does to the first, 
having the same mechanism in delivery, but with the 
direction of motion reversed. It occurs in not more 
than three per cent, of all positions of the vertex, 
but the same possibility exists here as in the third, 
that a few first positions were originally in the fourth, 
and rotated at an early stage at far above the inlet. 



THE MECHANISM OF DELIVERY. 79 

For as the third is converted into the second by an- 
terior rotation, so the fourth is converted into the 
first by the same movements and under the same cir- 
cumstances. Anterior rotation at the inlet is more 
likely to occur in this than in the third position, on 
account of the presence of the bowel to the left of 
the sacral promontory. The smallness of the left 
canal also favors anterior rotation, and therefore it 
cannot be said to be more difficult than the third. 

At the beginning of labor the occipi to-frontal 
plane coincides with the initial plane of the left ca- 
nal with the occiput behind, and with a similar sub- 
stitution of " right " for " left," the description of 
the third position throughout will answer for this 
one. 

I think we may be justified in drawing the follow- 
ing conclusions concerning occipito-posterior posi- 
tions of the vertex. 

First, they are not strictly natural positions. 
Secondly, they have nevertheless definite mechanisms 
of delivery which under favorable circumstances are 
alone sufficient to secure their birth. Thirdly, if the 
head and pelvis are of average size, their spontaneous 
delivery is attended with considerable delay in the 
labor and may be altogether impracticable. Fourth- 
ly, in a large proportion of cases the safety both of 
the mother and child will be promoted by artificial 
delivery. Fifthly, as the pelvic canals are of ellipti- 
cal outline, the head cannot turn so as to be placed 



80 HOW TO USE THE FORCEPS. 

in an occipito-anterior position until it presents a cir- 
cular plane whose diameter corresponds with the 
shortest diameter of the pelvic canal. Flexion is 
therefore the first requisite in all methods, whether 
natural or artificial. Sixthly, to make anterior rota- 
tion feasible, and with safety to the child, the shoul- 
ders must present with the back anteriorly, or be so 
rotated if they are not so originally. Seventhly, fail- 
ing this, the forceps will greatly assist in the requi- 
site compression, and also enable the physician to 
control the passage of the head over the perineum 
more effectually. 

II. The Face Presentation. — In the facial 
end of the cranium there is described a plane called 
the trachelo-bregmatic, which is named after its 
long diameter, which passes from the anterior border 
of the anterior fontanelle to the front of the neck. 
The transverse diameter of the plane, the bi-malar, 
measures about three inches, the long, or trachelo-breg- 
matic, about three and a half inches ; it is therefore 
somewhat elliptical in outline. It is nearly parallel to 
the cervico-bregmatic plane, but a little smaller in its 
circumference. This is the plane which in this pre- 
sentation corresponds in most particulars to the oc- 
cipitofrontal in the vertical positions ; entering either 
canal, and in two ways, with the lower end or chin 
in front or behind. The chin, then, or mentum, 
takes the place of the occiput in the nomenclature of 



THE MECHANISM OF DELIVERY. 81 

these positions, which are as follows : 1, Left mento- 
anterior ; 2, right mento-anterior ; 3, right mento- 
posterior ; 4, left-mento-posterior. This is also, as 
near as may be, the order of their frequency, which 
is not great in any position, since the face is said to 
present only once in two hundred and fifty or three 
hundred labors. They are supposed to occur as the 
result of displacement of the vertex, either from 
wrongly directed force due to some mechanical diffi- 
culty, or as the result of voluntary motion on the 
part of the child. I have seen two cases in which a 
shock to the mother a day or two before labor was at 
least followed by a face presentation. In one, the 
house in which the woman was, was struck by light - 
ning two days before labor came on, and the sudden 
start which one would naturally make under such 
circumstances may very well account for the dis- 
placement. In the other, a large picture fell from 
the wall upon the mother's head, having, no doubt, 
a similar effect. 

1. Left Mento- Anterior Position. — If a head 
is placed at the inlet in the third vertical or right 
occipito-posterior position, and moved well back 
under the right sacro-iliac arch, the parietal protu- 
berances may be made to impinge upon the sacral pro- 
montory behind and the ilio-pectineal line in 
front, while the occiput also rests upon the brim. 
This, as before shown, is usually resisted by flexion. 
But should the head nevertheless become impacted, 



82 HOW TO USE THE FORCEPS. 

the propulsive force acting through the vertebral col- 
umn of the child can move only the long arm of the 
lever, since the short one is wedged fast. Hence, ex- 
tension will occur, and as it takes place the head 
again becomes free. If the extension proceeds fur- 
ther than is required to bring the occipitofrontal 
plane below the level of the plane of the conjugate 
diameter, the line of force is thrown in front of the 
foramen magnum with increasing effect, and the ex- 
tension is accelerated. This continues until the 
trachelo-bregmatic plane takes the place of the oc- 
cipitofrontal, with the chin in front of the left ace- 
tabulum, and the anterior fontanelle opposite the 
right sacro-iliac symphysis. This, however brought 
about, constitutes the first position of the face pre- 
sentation. The comparatively small size of the 
trachelo-bregmatic plane makes it unimportant as 
well as uncertain whether there is any lateral obliq- 
uity or not. For the same reason we may say that 
the face per se offers no difficulties in delivery, and 
if the head was disconnected from the body it would 
at once descend to the level of the cervico-bregmatic 
plane ; after which the mechanism of delivery would 
be the same as in a vertical position. It is the man- 
ner in which the body and neck are made to enter 
the pelvis that constitutes the chief obstacle in its 
delivery. 

If the head and pelvis are of average size, the 
head descends in the right canal with its trachelo- 



THE MECHANISM OF DELIVERY. 83 

bregmatic plane coincident with the successive planes 
of the pelvic cavity. But as it descends, and the 
head approaches the inferior strait, the body, or 
rather neck, is drawn into the pelvis. This brings 
the length of the antero-posterior diameter of the 
neck to be added to the depth of the cranium, or in 
effect to the cervico-bregmatic diameter. This is 
too much for the pelvis to accommodate, and the 
head must be flexed to remove this difficulty. Flex- 
ion would have to occur in any event, if the head is 
to advance. But the line of force is through a point 
in advance of the centre of the head, and has no ten- 
dency to bring about flexion. This can only be ac- 
complished by the action of the secondary or peri- 
neal force, and the head is too high up to be reached 
by its influence. The farther the unaltered head 
moves under the propulsion of the uterine force, the 
greater is the difficulty, since the occiput and neck 
become more firmly impacted in the posterior part of 
the pelvis. The only resource of nature is to mould 
the head, by which process it becomes long enough 
to reach where it can be pushed forward and flexed 
by the perineal force. The neck is also liable to be 
compressed and moulded, from which great danger to 
the child arises, for the neck is ill-adapted for such 
pressure, and the circulation in the foetal brain is 
much interfered with. When the head is able to be 
flexed the difficulty is mainly over, the mere act of 
flexion causing the head to sweep over the perineum 



84 HOW TO USE THE FORCEPS. 

and to bring the face to the vulvar outlet, unless the 
neck is unusually short. During descent the head 
rotates, so that the chin appears in front and the 
anterior fonfcanelle behind, but this rotation is not 
due to any correspondence of the trachelo-bregmatic 
plane to the pelvic canal. This plane is too small to 
bring this about, but the cervico-bregmatic plane 
which follows it is the one which regulates the mech- 
anism. For this reason rotation is not as early in 
the facial positions, not occurring until the head has 
descended well in the pelvis, and the last named 
plane become engaged. It is then regular and com- 
plete, the head emerging from the vulva with the 
chin under the symphysis pubis. It escapes power- 
fully flexed, and is immediately extended again, after 
birth. Where the child is not large this mechanism 
is almost as natural as the corresponding vertical po- 
sition, the trachelo-bregmatic plane simply preced- 
ing instead of following the cervico-bregmatic plane. 
In fact, if the head alone were concerned, it would 
be a more favorable position than the third vertical 
position. But the implication of the neck and chest 
make it a dangerous one for the child, and tedious 
for the mother if delay is necessary to mould the 
head. 

Its clinical recognition is sufficiently easy at the 
beginning of labor, but if it is delayed at any point, 
and especially if it is detained at the inferior strait, 
this may become a little difficult. The tissues of the 



THE MECHANISM OF DELIVERY. 85 

face allow of a caput succedaneum, or swelling, to 
take place much more easily than the scalp, and the 
face may be greatly puffed up and distorted from this 
cause. Although as a general thing this swelling 
subsides soon after labor, there is always a risk of ir- 
reparable damage to the eyes, and lesser injuries. 
Delay in delivery is therefore to be deprecated, and 
should not be permitted to anything like the extent 
which would be allowed in another presentation. 

2. The Second, or Right Mento-Anterior, is 
similarly produced by the extension of a head origi- 
nally in the fourth or left occipito-posfcerior position 
of the vertex. It has precisely the same mechanism 
as the first facial position, with the direction of mo- 
tion reversed. It descends in the left canal, having 
at the beginning of labor the chin in front of the 
right acetabulum, and the anterior fontanelle oppo- 
site the left sacro-iliac symphysis. It does not need 
to be more particularly described. 

3. The Third, or Right Mento-Posterior 
Position, is produced by extension from the first 
vertical position. But it will at once be noticed that 
it cannot be produced in precisely the same way as 
a mento-anterior position. There is no chance for 
the wedging of the bi-parietal diameter in front. 
The extension of the head must, therefore, be attrib- 
uted to other causes. Barnes's theory of too great 
friction anteriorly may be tenable if coupled with an 
anterior diversion of the uterine force, but after all 



86 HOW TO USE THE FORCEPS. 

there is nothing more probable than the cause as- 
signed by Hodge, viz., the muscular movements of 
the child itself. It is well that it is not easily 
brought about, since it is especially difficult and dan- 
gerous. In this position the trachelo-bregmatic 
plane enters the right canal, as in the first facial po- 
sition, but with its long diameter reversed. The 
chin is found opposite the right sacro-iliac symphysis, 
and the anterior fontanelle in front of the left ace- 
tabulum. Difficulties begin early. In all positions 
the anterior part of the presentation moves less rap- 
idly than the posterior, because of the curved con- 
struction of the pelvic canals. Hence in this case 
it happens that the forehead remains at the brim 
while the chin and base of the cranium essay to ad- 
vance along the posterior part of the pelvis. This tends 
to bring the neck and chest at once into the pelvis, 
and the obstruction begins at once. For this means 
that a diameter of seven inches attempts to crowd into 
one of five inches in length. The head would naturally 
tend to rotate posteriorly with the chin to the rear, 
until a new influence is felt in the descent of the 
shoulders. In the mento-anterior positions the 
shoulders follow in the opposite canal from that in 
which the head descends, but in this, as in the occip- 
ito-posterior positions, the shoulders are thrown 
back over the right sacro-iliac arch. The shorter 
the neck and the speedier the impact of the shoul- 
ders the better, for the left or posterior shoulder is 



THE MECHANISM OF DELIVERY. 87 

thrown to the right of the sacral promontory, and 
the shoulders are thus brought over the entrance to 
the right canal. This causes the chin to rotate an- 
teriorly, and converts the position into a second or 
right mento-anterior position, when it is finished, as 
in that case. This anterior rotation may occur at 
the inlet, but may also take place between it and the 
inferior strait. It is closely analogous to the first 
mechanism of the third vertical position, and is the 
most favorable one in this position. If anterior ro- 
tation does not occur, and the shoulders enter the left 
canal with the back in front, the chin rotates into 
the median line posteriorly and the head becomes in- 
tensely extended. Xo relief is afforded even when 
the head is permitted to reach the inferior strait, 
since flexion cannot occur, nor could it assist if it did, 
and extension has already reached its limit. The 
further the body descends the tighter the wedging ; 
and anterior rotation, the only resource, becomes 
more and more difficult. Under any circumstances 
there must be a great delay until the head is so mould- 
ed as to be born in this fashion, and if it is at all 
large this is impossible. The face will also be fear- 
fully swollen and the head extremely " wire-drawn." 
The necessity for aid, either manual or instrumental, 
therefore, to promote rotation at an early stage, is 
clear. 

4. The Fourth, or Left Mento-Posterior Po- 
sition", has the same mechanism as the third, with 



88 HOW TO USE THE FORCEPS. 

the direction of motion reversed, and is therefore 
sufficiently described in the above account, with due 
substitution of " right " for " left." 

The treatment of the facial positions will be con- 
sidered incidentally in treating of the applicability 
of the forceps to such cases. 



PART II. 



THE FORCEPS 



INTRODUCTION. 

4 ' Sir," replied Dr. Slop, "it would astouish you to know 
what improvements we lave made of late years in all branches 
of obstetrical knowledge, but particularly in that one single 
point of the safe and expeditious extraction of the foetus, which 
has received such lights, that for my part (holding up his 
hands) I declare I wonder how the world has — " 

" I wish," quoth my uncle Toby, " you had seen what pro- 
digious armies we had in Flanders." — Sterne. 

" To procure easy travails of women, the intention is to bring 
down the child, whereunto they say the load-stone helpeth ; 
but the best help is to stay the coming down too fast. " — Bacon. 

Whe^" Lord Bacon penned this sage remark, the 
forceps were unknown, and in the light of other 
days we are reminded of the fox and the grapes, 
and similar instances of the depreciation of the unat- 
tainable. For almost ever since their rude begin- 
ning in the instrument of Chamberlen there have 
been many who shared in the views of Dr. Slop, as 
to the blessings of the forceps. When we think of 
what the instrument can do, and of the numberless 
lives which it has saved, it is difficult to avoid his en- 
thusiasm, and yet it must be confessed that he was 
aptly answered. For there is a debit as well as a 
credit side, and it needs little research to learn that 
the forceps have also been chargeable with much 
harm, so that in many minds even now the balance 



92 HOW TO USE THE FOKCEPS. 

is doubtful concerning them. That the fault is not 
in the forceps, but in the users, it will be my en- 
deavor to show. They are not simply a pair of 
tongs, to be applied — somehow — to the child, and 
pulled upon — somehow — until it is dragged out, but 
a carefully adapted instrument, intended to be ap- 
plied in a definite way and used in a definite man- 
ner, according to the case in which they are used. 
And when used with understanding, and under 
proper conditions, they fully justify all the eulogy 
which has ever been bestowed upon them. 

The obstetric forceps are composed of two sepa- 
rate and similar pieces of steel, each of which is fash- 
ioned into a blade and handle. The pieces are made 
to cross each other near their middle, or at the junc- 
tion of the blade and handle, at which point a de- 
vice known as a lock is contrived so that compression 
of the handle will cause an approximation of the 




Fig. 21. — Davis Forceps (upper view). A, the blades ; 
B, the handles ; C, the lock. 

blades. They are, as has been well said, a pair of 
steel hands, to be placed one on each side of the 
child's head, to grasp it and draw it from the 
mother. Like hands, too, they can grasp lightly or 
forcibly. They are intended, primarily, to deliver 



INTRODUCTION. 93 

a living child from an uninjured mother. But they 
can also be used to squeeze and drag down a dead 
child, in the place of craniotomy. Whether this is 
ever proper is another question. 




Fig. 22. — Davis Forceps (side view). 

The first idea, then, of the forceps is of a tractor, 
to be used to supplement or supplant the expulsive 
forces of the mother. To adapt them for further 
usefulness in conditions of disproportion between the 
head and pelvis, they are also made capable of com- 
pressing the head so as to diminish its diameters, 
and thus constitute a compressor. They may also be 
used to further the natural mechanism by flexing, 
extending, and sometimes by rotating the head, and 
in this sense may be regarded as a lever, but any use 
of the forceps which implies a leverage upon the sides 
of the obstetric canal, i.e., upon the mother's tis- 
sues, is unscientific, dangerous, and criminal. A 
properly constructed forceps will embrace these three 
functions in one, the form of the instrument being 
determined by these requirements. It would be in- 
teresting to trace historically the successive changes 
which have been made in the forceps during the two 
hundred years of their employment, but as this would 



9tt HOW TO USE THE FORCEPS. 

be of little practical value, it will be better to con- 
sider only the ideal forceps as at present adapted. 

For convenience we will consider first the blade, 
which is the part in front of the handles, then the 
handles, and lastly the lock. 

1. The Blades. — The blades should be large 
enough to cover a considerable part of the surface of 
the head, so as to hold it securely, and with as little 
pressure as possible on any one part. And since they 
are frequently demanded, because of the tight fit of 
the head in the pelvis, they must not take up any ad- 
ditional room by adding to the diameter of the pre- 
senting plane of the head. For these reasons the 
blades should be wide, but with a large fenestrum, 
through which the parietal protuberances of the head 
project. In this way they will not add a fraction to 
the size of the head. If the blades are narrow they 
will not exert so equable a pressure upon the head. 
Also in this case the fenestrum will be correspond- 
ingly small, and the convexity of the head cannot so 
well protrude between the branches of the blade ; the 
diameter is therefore liable to be increased by such an 
instrument. A good, wide blade, with a correspond- 
ingly wide fenestrum, is the first requisite in the 
forceps. It is alleged by some that a wide blade is 
more difficult to introduce than a narrow one — 
which is in a measure true, but since the wide blade 
can always be readily introduced in any case which is 
suitable for the application of the instrument, it is of 



IJSTTKODUCTION. 95 

no consequence that another blade can be more read- 
ily used. A blade only a finger-breadth wide could 
be introduced still more easily, but would be of no 
use. A width of two to two and one-eighth inches 
will be sufficient, with a fenestrum one and one-half 
inches in breadth. 

a, Head Curve. — "When a pair of scissors, for in- 
stance, is opened, the points widely diverge, so that 
an instrument made in this way with straight blades 
would have a very slight grasping power. In fact, 
the only hold which such blades would have upon an 
object would be such as powerful lateral pressure 
would give. This in the forceps would be a great ob- 
jection, since the object to be grasped is the more or 
less compressible head of a living child, and such pres- 
sure is liable to injuriously affect the intra-cranial 
circulation, if not the integrity of the brain itself. 
Compression of the head is at times desirable and 
necessary, but in many, if not most, instances, all 
that is required of the instrument is that it shall hold 
the head securely with a minimum of compression. 
For this reason the blades are bowed outwardly to con- 
form to the curvature of the head. This is known 
as the head-curve of the forceps. It must not be so 
slight that the head will readily slip from between the 
blades, nor must it be very great, else there would be 
great difficulty in applying them. With a proper 
head-curve the tips of the blades will approximate to 
such an extent, when the instrument is applied, that 



96 HOW TO USE THE FORCEPS. 

traction upon the blades brings their distal end upon 
the farther end of the head, so as to not only secure- 
ly hold it, but also to push it onwards. "When for- 
ceps are said to slip during their use, one of two 
things is certain ; either the head-curve of the in- 
strument is insufficient, or the blades have not been 
properly applied. In the Davis forceps the tips of 
the blades are one-half inch apart when the instru- 
ment is closed, and when open sufficiently to hold a 
head measuring four and a half inches in the bi- 
parietal, the tips are two and three-quarter inches 
apart. It is obvious that if the head is really in the 
blades of this instrument, they cannot slip unless the 
steel blades are so thin as to allow of their being 
sprung outwardly at the tips. This latter is an ac- 
cident which I think does occasionally happen in 
some forceps, but is guarded against in the Davis 
forceps by a secondary head curve in the blades, 
namely, a curving from above downwards. This 
twisting of the blades makes them much stronger, for 
the outward acting force of the child's head is ap- 
plied almost edgewise to the arms of the blades, 
instead of through their thinnest diameter. This 
secondary curve also adarjts the instrument more ex- 
actly to the convexity of the head. The forceps are 
also held upon the head by the pressure upon them 
of the soft parts and pelvic walls, and in cases where 
there is not a tight fit and the forceps are applied 
merely for lack of uterine contractions, an instru- 



INTRODUCTION. 97 

merit with no head-curve at all may be sufficient to 
withdraw the head. In difficult cases the head-curve 
is absolutely necessary, arid in any event, the instru- 
ment which is useful only in the cases where it is 
least needed is not a desirable one. 

by Pelvic Curve. — The curvature of the pelvic 
tube in its whole length is considerable. As before 
shown, the child in escaping from the vulvar outlet 
takes a direction almost exactly opposite to that in 
which it enters the pelvis. Much of this curvature 
is indeed in the soft parts, and therefore both varia- 
ble and capable of being overcome by a straightening 
pressure against the walls. It is true that a pair of 
forceps which are nearly straight quoad their length 
can be made to seize the head when quite high up in 
the pelvis and even at the inlet, but it is much more 
convenient to have the instrument conform to the 
curvature of the pelvis. This is known as the pelvic 
curve, and is surprisingly different in different in- 
struments, varying from a. barely perceptible curve to 
one in which the ends of the blades are nearly at 
right angles to the rest of the instrument. The 
curvature of the male catheter, for instance, is com- 
paratively uniform, and there is no reason why so 
great a diversity should exist in the forceps in this 
respect. The pelvic curve of the Davis forceps, which 
is greater than that of most instruments, seems to me 
to be most suitable. It not only enables us to apply 
the blades to the head at any point with great facil- 



98 HOW TO USE THE FOKCEPS. 

ity, but it allows them to be adapted to tbe head in 
a superior manner. The blades, by reason of this 
curve, will be more nearly parallel to the axis of the 
presenting plane of the child's head than if the 
blades were straighter, and it will therefore be easier 
to make the traction in the proper direction. 

There are, then, two valid reasons for a consider- 
able pelvic curve ; first, that it allows of greater ease 
in application, and second, that the blades will be 
applied to the head in a more desirable way. Such 
an instrument can be used at any point, the straight 
forceps only when the head is at the inferior strait, 
without great pressure upon the perineum, and con- 
sequent discomfort to the mother. The exact man- 
ner of curvature, whether it shall be gradual from 
the lock to the tip, or whether it shall begin at some 
distance in front of the lock, is a matter of some mo- 
ment. 

In the Davis forceps (Fig. 21), the shanks of the 
blades are continued in front of the lock, straight, 
parallel, and close together, for an inch and a half 
before either the pelvic or head-curve begins. This 
insures that the lock shall be outside of the vulva in 
most cases, even when they are used at the inlet. 
In many instruments, both curves begin at the lock, 
which seems to me to be a disadvantage, since the 
blades are relatively shorter and are unnecessarily 
wide in the immediate neighborhood of the lock. 
The pelvic curve of the Davis forceps is peculiar, be- 



INTRODUCTION". 99 

ing increased by widening the fenestrum posteriorly, 
or rather by having the two bars of the blade nearly 
parallel, and making the curvature principally in the 
lower bar. This gives them an exceptionally grace- 
ful appearance, which can be appreciated better by 
direct inspection of the instrument than by any de- 
scription. 

The blades are by these curves fully adapted for 
seizing and securely holding the head, but they must 
have handles to facilitate their introduction and to 
assist in traction, while to admit of compression they 
are made to cross each other afc the lock. 

2. The Handles. — The handles are continuous 
with the blades, and are made of even more diverse pat- 
terns than the latter. Some are made of great length, 
in order to increase the leverage power of the instru- 
ment. Some are provided with rings or shoulders, to 
enable more powerful traction to be made with them. 
Some are provided with a blunt hook at the extrem- 
ity, for the same purpose, and for convenience of 
having a double instrument. Some are made in 
pieces, so that the handles can be made either long 
or short. I again select the Davis forceps as possess- 
ing the most desirable handles. They are not bulky, 
are straight and uncomplicated, are long enough to 
allow of being comfortably grasped by one hand, or 
even by two, if that were ever necessary. Their 
length is between four and five inches behind the 
lock, which is enough. In speaking of traction dur- 



100 HOW TO USE THE FORCEPS. 

ing the use of the forceps, I will explain why I do 
not regard the handles as the important agent in pro- 
ducing traction, and also show that the length above 
mentioned is sufficient for the proper use of the lev- 
erage power of the instrument. If I am correct in 
stating that such handles are sufficient for all practi- 
cal purposes, their advantage over other forms is ob- 
vious. They are small and convenient, and there is 
nothing about them to get oat of order or in the 
way. The rings and shoulders and blunt hooks are 
in the way during introduction, and have the ad- 
ditional disadvantage of inviting us to make trac- 
tion in the wrong direction. In some forceps the 
handles are entirely of steel, and are usually so small 
that a firm grasp becomes painful to the operator. 
It is better to affix to them pieces of wood or hard 
rubber. It is hardly necessary to add that both the 
blades and handles should have all sharp edges re- 
moved, and carefully rounded so as to avoid injury 
to the tender structures about which they are used. 

3. The Lock. — The lock is by no means the least 
important part of the forceps. There are three 
forms of lock in common use : the English, or mor- 
tise-lock, the screw and slot-lock, with which the 
Hodge forceps is usually provided, and the flat but- 
ton-lock. The first is the most objectionable. In 
the first place, the danger of pinching the maternal 
tissues when the lock is close to the vulva is greater 
than in any other. Secondly, the forceps may be 



INTRODUCTION. 101 

locked when the blades are not in exact apposition, 
but when one blade is introduced a little further 
than the other. But as soon as traction is made the 
blades will slide into their proper relation, in which 
case the blade which has been in advance will usual- 
ly injuriously scrape the child's head and either 
bruise or lacerate it. This can be avoided if suffi- 
cient care is taken, but it is better to have a lock 
which utterly prevents it. Thirdly, the blades fitted 
with this lock cannot at a glance be distinguished 
one from the other, but must be fitted together be- 
fore we can tell which is the right and which the 
left blade. This may appear to be a trivial matter, 
but any one who has used all kinds will appreciate it. 
In the second form of the lock one blade is provided 
with a slot, and the other with a pivot which termi- 
nates in a large upright screw-head. When the 
blades are opposite each other, upon the head, the 
pivot is just opposite the slot, and may be pushed 
into it. The screw-head is then rotated between the 
thumb and finger until the lock is made fast. 

There are two objections to this form. First, the 
looseness of the lock allows of the pivot being inserted, 
into the slot when the blades are introduced to an 
equal length, but before they are exactly opposite, 
and when they are somewhat tilted. Then, when the 
screw is tightened, they may be forced into exactness. 
Secondly, the projecting screw-head is often in the 
way, and when the lock is close to the vulva cannot 



102 HOW TO USE THE FOKCEPS. 

be turned with ease. These objections can be mainly 
overcome by screwing down the pivot so as to make 
a close fit before beginning to introduce the blades, 
but there still remains the fact that the projection is 
too great for convenience. In the third form one 
blade is provided with a slot and the other with a 
closely- fitting pivot which is capped by a flat button- 
like expansion. When the blades are in exact oppo- 
sition the slotted blade glides under the button and 
the instrument is locked, but unless the instrument 
is exactly adjusted this cannot be done. We have, 
then, in this lock a safeguard against a faulty appli- 
cation, and when the instrument is locked a guaran- 
tee that they are properly applied. The pivot is so 
low as not to be in the way, and the two blades can at 
once be distinguished from each other. With the 
last two locks, the slotted blade is known as the fe- 
male blade, the one with the pivot, the male blade. 
Otherwise the blades are distinguished as right and 
left, according to the side of the pelvis to which they 
are applied, and sometimes anterior and posterior or 
upper and lower, which are variable terms, for one 
blade may be in either position according to the case 
in which they are used. So far as nomenclature is 
concerned the slot and pivot lock, then, is much more 
convenient. I will not undertake the invidious task 
of pointing out the imperfections of the various for- 
ceps now in use ; but will simply state my belief, 
founded on the principles above stated, that the Da- 



THE APPLICATION" OF THE FORCEPS. 103 

vis forceps provided with the button-lock, as made 
by J. H. Gemrig, of Philadelphia, from a reliable 
model, is the best instrument for general use. It is 
the instrument used by the accomplished Professor 
Charles D. Meigs, who declared that it was as near 
perfection as could be attained, and did not attempt 
to modify it, and has been used for many years by 
such veteran obstetricians as Ellwood Wilson and 
Albert H. Smith, of Philadelphia. Care should be 
taken in procuring the instrument, for those made 
by several manufacturers are not correctly made, and 
leave out some of its most important characteristics. 

Such forceps as have special forms or modifica- 
tions for a particular purpose may be briefly noticed 
in treating of the use of the instrument. There is 
no doubt that special skill in the use of any double- 
curved forceps may enable an operator to use it effect- 
ively ; the same amount of skill devoted to the Da- 
vis forceps will bring a better return. I say noth- 
ing of the straight forceps, because it is nearly obso- 
lete, and every text-book bears witness against it ; 
nor of forceps for use upon the breech, as this appli- 
cation of the instrument is not yet well established. 

THE APPLICATION OF THE FORCEPS. 

The forceps, being specially designed and adapted 
for the head, may be applied to it in any of its pre- 
sentations and positions, and at any point in its 
course. The indications for their application will be 



104 HOW TO USE THE FOECEPS. 

discussed in another place, so that we will assume a 
suitable and uncomplicated case, in which the os 
uteri is fully dilated. Although the head may be ar- 
rested in any part of the pelvis, we are practically 
seldom called upon to apply the forceps except in 
two situations, viz., when the head is at the inlet or 
at the outlet of the pelvis. It is also necessary at 
times when the head is resting upon the perineum 
and in great measure through the outlet, but as the 
tube is single from the outlet onwards, there is no 
difference in the application of the instrument. At 
the inlet the conditions are decidedly different, and 
the method of using the forceps is likewise different. 
I. We will consider, first, the application when the 
head is at the inlet and in the first vertical position 
(L. 0. A.) in a pelvis which is of normal propor- 
tions. Certain preliminaries are requisite. First, 
the forceps are to be taken from their bag, or case, 
and placed in a basin of warm water, so that they 
shall be of the proper temperature. Care should be 
taken that the blades are not rattled against each 
other while handling them, as the clang of steel is a 
peculiarly disagreeable sound to those who are about 
to be " operated upon." Next, the woman should 
be placed in a proper position : lying upon her back, 
transversely in the bed, with the hips brought to the 
edge, so that the vulva overhangs the edge and with 
the feet placed upon two chairs. One, or better two, 
sheets may be placed over the limbs, so as to avoid 



THE APPLICATION OF THE FORCEPS. 105 

any exposure, but the vulva should be uncovered so 
that the operator shall see exactly what he is about. 
Eight-minded persons will offer no objections to any 
necessary procedure, and it is better to wound the 
feelings than the pelvic tissues by uncertain manipu- 
lations under the bed-clothes which are certain to get 
in the way. The English prefer to apply the forceps 
with the woman upon her side, which is much more 
difficult and sometimes well-nigh impossible. As we 
can never be sure beforehand of the amount of diffi- 
culty we shall encounter, it is best to secure the most 
favorable position at the start. A third chair should 
then be placed between the others, upon which the 
operator is to sit, and the forceps are to be placed 
within reach. A supply of lard and several towels 
complete the equipment. If there is any doubt as to 
the condition of the bladder, a catheter may be pass- 
ed, but this is sometimes impracticable. I assume 
that the rectum has been emptied by an enema. 

Where are the blades to be applied in the first po- 
sition at the inlet ? There are several reasons for the 
unhesitating answer, on the sides of the child's head. 
First, they will fit the head better. Secondly, they 
will be less likely to injure the head when com- 
pressed than when in any other situation. Thirdly, 
they will be applied in a very definite relation to the 
head, so that when we move them in any direction we 
know exactly in what way the presenting plane of 
the head will be disturbed. Fourthly, we can, if 



106 HOW TO USE THE FORCEPS. 

necessary, flex or extend the head, or otherwise con- 
trol its relations mnch better when the head is 
grasped in this fashion. In fact, flexion of the head 
is next to impossible when the forceps are otherwise 
applied. Fifthly, the head can be reduced in size 
more certainly than in any other way, since the ap- 
proximation of the blades compresses and reduces the 
bi-parietal diameter, while forced flexion of the head 
can be made to reduce the antero-posterior diameter, 
by substituting the cervico-bregmaticforthe occipito- 
frontal. And lastly, the application is no more diffi- 
cult than any other in the undeformed pelvis. The 
head, in the position under consideration, is quite 
closely applied to the pelvic brim upon the right side 
of the pelvis and upon the left side in front. One 
part of the head is at some distance from the brim, 
viz., the left parietal region, which is opposite the 
left sacro-iliac arch. One blade of the forceps then 
can very easily be placed just where we want it, on 
the left side of the head, since there is a roomy pas- 
sage for the blade. The blade which is to be oppo- 
site this one niust be insinuated between the right 
side of the head and the pelvic rim to which it is 
closely adjusted. But what is true of this latter 
blade is true of both in any other method of applica- 
tion. It is only when the blades are applied to the 
sides of the head that even one of them has a place 
provided for it, as it were. 

The next consideration of importance is, which 



THE APPLICATION" OF THE FORCEPS. 107 

blade should be first applied ? In answering this we 
will notice that one side of the head is posterior and 
remote, namely, the left side ; the other is anterior 
and near. The fact that one side is more posteriorly 
placed than the other will decide the question 
for us, for if th6 anterior blade was first passed it 
would be in the way during the application of the 
second. These questions being settled, the oper- 
ator sits in front of the vulva, takes up the male 
blade of the forceps, and thoroughly anoints the part 
to be introduced and also his right hand. The lat- 
ter is to be introduced into the vagina as far as the 
thumb, or until the finger-tips can be placed between 
the os uteri and the head. Sometimes the introduc- 
tion of two fingers will be sufficient for this purpose. 
If so, all the better, but this precaution should never 
be omitted, lest the blade should pass to the outside 
of the cervix, when even a slight amount of force 
may result in great damage to the maternal tissues. 
The handle of the forceps should be securely grasped 
in the left hand ; not held like a pen, which for an 
object of its weight gives an insecure hold, but held 
firmly so that it can be introduced with precision. 
A firm hold does not imply a forcible use, but on the 
contrary, the ability to grade force with entire deli- 
cacy. The tip of the blade is then inserted in the 
vulva resting against the palm or surface of the fin- 
gers, while the tip of the handle is held perpendicu- 
larly above the middle of the mother's right groin. 



108 HOW TO USE THE FORCEPS. 

Since this blade is to traverse nearly the whole pos- 
terior curvature of the pelvis before coming in con- 
tact with the head, the pelvic curve of the instrument 
is to be first considered, and it is to be passed almost 
exactly as we would pass a male catheter into the 
male bladder. As the blade glides upwards, the tip 
of the handle moves almost directly forward, and with 
little depression until the blade has reached the lower 
limit of the side of the head. The head curve of the 
forceps must now be considered, and the blade made 
to pass around the convexity of the head. As this 
movement is executed the handle of the forceps is 
made to approach and cross the median line, and at 
the same time is rapidly depressed. As the blade 
continues to be moved onward in the line of its pel- 
vic curve to a certain extent, the motion is somewhat 
spiral ; but the greater part of the motion in this di- 
rection is effected during the first movement ; hence, 
during the second, the line of motion of the tip of 
the handle is almost straightly diagonal from above 
downwards. When the introduction is complete the 
blade is in the free space under the left sacro-iliac 
arch, and applied to the left side of the child's head. 
The handle will rest against the perineum and will 
have its face turned somewhat to the left thigh of the 
mother, its direction being nearly in the axis of the 
initial plane of the right canal. As soon as the tip of 
the blade is felt to be between the cervix uteri and the 
head, the hand or fingers may be withdrawn from the 



THE APPLICATION OF THE FORCEPS. 109 

vagina. The introduction of the male blade is al- 
most without exception very easy. If properly direct- 
ed to its destination it slips into place almost from 
its own weight. The second blade does not enter 
quite so readily, but, under ordinary circumstances, 
its introduction is not difficult. The right hand is 
freed from its inunction with a towel and takes up 
the female blade, which with the left hand is then 
anointed as in the case of the preceding blade. The 
right side of the head is much nearer than the left. 
It will therefore usually suffice to introduce two 
fingers of the left hand as a guide and safeguard be- 
fore passing this blade. From the proximity of the 
right side of the head, the head- curve of the blade 
has to be considered almost synchronously with the 
pelvic curve. For almost as soon as the blade begins 
to be introduced it must be curved around the head. 
It is therefore held nearly at right angles to the me- 
dian line, with the handle in the line of the mother's 
left groin, while the tip of the blade is inserted in 
the vagina, resting against the palmar surface of the 
fingers. The part to which we desire to apply the 
blade is almost directly over the right obturator fora- 
men. The handle is therefore at once moved towards 
the median line, and depressed as soon as it is clear 
of the mother's left leg, while it is pushed onward at 
the same time, so that the line of movement is con- 
tinuously spiral. I have said that the head was 
closely applied to the rim of the pelvis on the whole 



110 HOW TO USE THE FORCEPS. 

of the right side of the latter ; but if the head is well 
flexed the frontal end will not entirely fill up the right 
sacro-iliac arch. Hence there is a tendency in this 
blade to slip posteriorly into this opening. If it 
does the blades will not be opposite, but their con- 
cavities will both look forward and they will not grasp 
the head and cannot be locked. To avert this we 
keep the blade well forward during its introduction, 
and this can be promoted by a simple manoeuvre. 
One finger of the left hand is retained in the vagina 
and placed under the upper bar of the blade. With 
this we can push the blade upwards while the right 
hand is urging it onward. The amount of force re- 
quisite for the application of the second blade is usu- 
ally greater than that demanded by the first. Where 
the forceps are applied only on account of uterine in- 
ertia, rather than for any detention from dispropor- 
tion, or where the head is resting above the inlet 
rather than engaged in it, there is not a great differ- 
ence. The amount of force which is justifiable can- 
not, of course, be measured, but when the operator 
is thoroughly aware of the true relations of the head 
to the pelvis, it is never very great. When the sec- 
ond blade is thoroughly introduced its handle crosses 
that of the first and the slot comes just opposite the 
pivot and a slight compression of the handles locks 
the instrument. If the parts of the lock do not en- 
tirely and easily coincide, we must withdraw the sec- 
ond blade and apply it with more care until it can 



THE APPLICATION OF THE FORCEPS. Ill 

be brought in proper relation with the first. When 
this is accomplished without difficulty, we may be 
certain that the head is grasped in its bi-parietal di- 
ameter, and may proceed to its extraction in the full 
confidence that we know exactly what has been 
done. The position of the handles when the forceps 
are thus applied is instructive. The head being 
grasped in its bi-parietal diameter, the face of the 
handles is directed towards the left side. 

But we may notice also that the handles are not in 
the median line, but point decidedly to the left of it. 
And the higher the position of the head the greater 
the divergence of the handles from the median line. 
If the head was centrally placed in the inlet, as stated 
by Hodge, this would not be the case. But its cen- 
tre is decidedly to the right of the median line as 
we have already stated, and therefore the handles 
occupy this position, which is a clinical proof of the 
truth of the views herein entertained of the mechan- 
ism of labor. The practical bearing of this will be 
discussed under the head of traction. 

It sometimes happens that when both blades have 
been apparently correctly introduced, the parts of the 
lock are still too far apart to be united. This is often 
due to the fact that they have not been introduced 
far enough. In this case the handles may be taken 
one in each hand and pressed well against the peri- 
neum, when they will usually lock. When the head is 
above the brim this is always necessary, and when 



112 HOW TO USE THE FORCEPS. 

fairly engaged in the inlet the handles are quite close 
to the perineum when fully applied. Care should be 
taken in locking the blades not to pinch the vulvar 
tissues or allow hairs to be entangled in the lock. 

The application of the forceps to the sides of the 
head when at the superior strait — is taught by 
Dewees, Meigs, and Hodge, and by a small minority 
of English and continental authors. Even these ad- 
mit exceptions, and state that the blades cannot al- 
ways be thus applied, and Dr. Davis himself was 
sometimes unable to introduce the second blade of 
his forceps upon the right side of the head. Nearly 
all, however, admit the advantages of this method, 
and merely allege its difficulty. In place of it many 
recommend that the blades shall be passed with refer- 
ence to the pelvis, one upon each side, in which case 
the head will be grasped obliquely. The disadvan- 
tages of this procedure are mentioned by implication 
in the enumeration of the advantages of the method 
already described. 

There is a much greater risk of injuring the head, 
in addition to the less perfect control which is ob- 
tained of its movements. I believe that the objec- 
tion to the cephalic application of the blades is un- 
warranted and founded upon several erroneous con- 
clusions. 

First, there is not a sufficient discrimination 
made between the application of the forceps in nor- 
mal and deformed pelves. It is probable that in 



THE APPLICATION OF THE FORCEPS. 113 

some cases of pelvic deformity tlie blades cannot be 
applied to the sides of the head. But I utterly deny 
even the difficulty of application in the normal pel- 
vis, except when from the extreme size of the head 
no method is adequate, as in hydrocephalus. This 
is an important point, since the rule should not be 
conformed to the cases of deformed pelves, which 
are comparatively rare, but to those in which the pel- 
vis is normal, which are much more frequent. 
Leishmann says explicitly : *■ Delivery by the long 
forceps may practically be considered as an operation 
in which the head is arrested by reason of contrac- 
tion of the pelvic brim" (Syst. p. 4:Q6). Secondly, 
there is not enough difference made in the manner 
of introducing the blades. The English have indeed 
hardly given in their adhesion to the use of the 
long, double-curved forceps, having shown a tend- 
ency to protract the infancy of the instrument in a 
characteristic way. Thirdly, there is not enough 
difference made in the manner of introducing the 
second blade, and it is improperly introduced. The 
teaching of Baudelocque, Levret, and Cazeaux is 
substantially the same as that of Leishmann, which is : 
" This blade may also be passed in the direction of the 
hollow of the sacrum." Schroeder, p. 177, is more 
explicit. " Ho takes the right blade in the right 
hand, . . . and proceeds in the same way as just de- 
scribed. Both blades are now situated somewhat be- 
hind, and in order to lock the forceps, either both or 



114 HOW TO USE THE FORCEPS. 

at least one of the blades must be brought forward ; 
in the first head position the right-hand blade." In 
other words, one blade is to be passed under the left, 
the other under the right sacro-iliac arch, after 
which either the right blade is to be brought for- 
ward and opposite the other, or both are to be 
brought to the sides of the pelvis until they are op- 
posite. It is no wonder that with such directions 
the application is difficult. Barnes, p. 59, says : 
" The instrument held in the right hand lies nearly 
parallel with the mother's left thigh, or crossing it 
with only a slight angle. The point of the blade is 
slipped along the palmar aspect of the fingers in the 
vagina, across the shank of the first blade in situ, 
inside the perineum toward the hollow of the sacrum. 
As the point has to describe a helicine curve to get 
round the head-globe, and forward in the direction 
of Cams' s curve, the handle is now depressed and car- 
ried backward until the blade lies in the right ili- 
um." I do not wonder at his abandoning the at- 
tempt to apply the forceps to the sides of the head, 
if the second blade is passed in this fashion. But if 
it is held at first, not parallel with the mother's 
thigh, but at right angles with it, the blade may be- 
gin to curve around the head very soon after it en- 
ters the vagina, and can be kept in front with little 
difficulty. And so far from it being proper to pass the 
second blade under the right sacro-iliac arch, and 
then bring it forward, if we are so unfortunate as to 



THE APPLICATION OF THE FORCEPS. 115 

get it in this position, it should at once be withdrawn 
and the attempt be renewed to pass it properly. One 
reason which is given by Barnes, Fauntleroy, and 
others, for the pelvic application of the blades is 
that it dispenses with the need for our knowing the 
position of the head when using the forceps. But 
after they are on, it is of great importance that we 
should know in which canal the head is situated, and 
whether our efforts are or are not flexing or extending 
the head, which cannot be done unless we know the 
position of the head. To apply the forceps in a haphaz- 
ard way to the head is a very unscientific procedure, 
and is not safe even for experts with the forceps, much 
less for the unskilled and careless, to whom the doc- 
trine that we need not know the position of the head 
comes with peculiar comfort. There are occasionally 
met with cases in which the determination of the po- 
sition is extremely difficult, but to make these the 
basis of a rule is not an indication of progress in our 
science. 

The rules here given for the application of the 
forceps to the first position of the vertex at the inlet 
apply equally well to the third vertical and to the 
first and third facial positions. In other words, 
whenever the head is in the right canal, the forceps 
are to be thus applied. As this embraces the great 
majority of cases in which they are used, the doc- 
trine of chances would lead us to apply them in this 
way whenever we were uncertain as to the position of 



116 HOW TO USE THE FORCEPS. 

the head. Any uncertainty, however, can usually 
be cleared up when the hand is introduced as a pre- 
liminary to passing the first blade. 

"When the head is in the second or fourth positions, 
or in the left canal, the order of applying the blades is 
reversed. The female blade is first to be introduced 
and passed under the right sacro-iliac arch. The male 
blade is then introduced upon the left side and in front 
in a similar manner to the introduction of the second 
blade in the first position. But when this is done the 
forceps cannot at once be locked, since the blade with 
the pivot will come on top of the blade with the slot. 
"We therefore take hold of each handle, press them 
well back towards the perineum, and at the same 
time slip the handle of the female blade over and across 
the male blade, when the parts of the lock will be in 
proper relation to one another. This is a slight incon- 
venience, but by no means as great as that attending 
the reverse method of introducing the blade, in which 
case the anterior blade will be decidedly in the way 
while introducing the posterior one. The manoeuvre 
should be performed with care and gentleness, re- 
membering that the points of the blades are within 
the uterus, and are partaking of the motion commu- 
nicated to the handles. When the forceps are ap- 
plied upon a head in the left canal, the handles will 
be observed to extend nearly in the axis of the initial 
plane of that canal, being to the right of the median 
line and with their face directed to the right. 



THE APPLICATION" OF THE FORCEPS. 117 

II. At the outlet. It is occasionally necessary to ap- 
ply the forceps while the head is between the inlet and 
outlet of the pelvis, and therefore imperfectly rotated. 
The application is made in substantially the same 
way to the sides of the child's head. Such cases are 
comparatively inf requen fc. If the head passes the in- 
let it is rarely detained until it reaches the inferior 
strait, and has accomplished its rotation. At this 
point, or when resting upon the perineum, the for- 
ceps are most frequently needed. As the sides of the 
head correspond to the sides of the pelvis, the long 
diameter of the head being in the median line, the 
blades will be applied to the opposite sides of the pel- 
vis, in the following manner : Two fingers of the 
right hand being introduced as a guide, the male 
blade is taken in the left hand and held at right an- 
gles to the median line, with the tip of the blade in 
the vulva. As soon as the blade reaches the left side 
of the head the handle is moved spirally downwards, 
backward, and onward, while the blade curves around 
the head and onwards into the pelvis. The same 
procedure with changed hands is repeated with the 
female blade, when the handle will be found in the 
median line, but not pressed agaiust the perineum as 
when the application is made at the inlet. But no 
matter where the head is, if it has not completely ro- 
tated, the application should be made to the side of 
the head, which cannot be denied to be perfectly fea- 
sible at the outlet, whatever may be thought of the 
higher operation. 



118 HOW TO USE THE FORCEPS. 

III. The forceps are sometimes applied upon the 
after-coming head, after the delivery of the body and 
arms of the child. The method is the same as when 
the head comes first, the body being held as far as 
possible out of the way by an assistant during their 
application and use. The usefulness of the forceps in 
these cases, is, however, questionable. Only under 
exceptional circumstances can the child live during 
the time requisite for their application. If, how- 
ever, manual extraction should fail, it is commonly 
advised that they should be used, though Schroeder, 
for example, does not even mention the possibility of 
their being required. It is worthy of note that 
Barnes, p. 75, in speaking of their application to the 
after-coming head at the brim, says : ' ' The head is en- 
gaged with its long axis more or less nearly in the trans- 
verse diameter of the brim. The blades should grasp 
it in an oblique diameter, approaching the anteropos- 
terior." If this is difficult when the head comes first 
it is much more difficult in head-last labors. Neither 
is it true in any but deformed pelves that the head 
enters the brim transversely, for it enters either the 
right or left canal in the same fashion as when it 
comes first ; except that it is upsidedown. The head 
should therefore, if possible, be grasped by the for- 
ceps in the same way, but the body and neck of the 
child are so much in the way, that if manual efforts 
to deliver the head fail, the forceps will rarely suc- 
ceed, and craniotomy will be the only resource. Meigs 



THE APPLICATION OF THE FORCEPS. 119 

taught that the practitioner should always carry the 
forceps to every case, lest in a breech case the child 
should die before we could get them. But, highly 
as I esteem the instrument, I fear that they have 
saved few lives under such circumstances. 

IV. A few general remarks upon the application 
of the forceps in any case may here be made. First, 
they should not be introduced during a " pain " or 
uterine contraction. The passage of the blade 
through the cervix will often excite a contraction, 
which speedily subsides if the manipulation is sus- 
pended, after which it may be renewed. Secondly, 
the use of anaesthetics is neither necessary nor advisa- 
ble. The introduction of the forceps is not painful, 
or at least no more painful than an ordinary uterine 
contraction. The sensations of the woman are also 
an invaluable guide and safeguard during their intro- 
duction. If you are causing pain it is probably be- 
cause you are not passing the blade properly, and the 
exclamations of the woman will speedily notify you 
of the fact. When the blades are locked, you are in 
no danger of pinching the maternal tissues if the 
locking is painless. But if the woman is anaesthet- 
ized you are left entirely to your own discretion. 
Although a careful and skilful operator will not do 
auy harm with them under any circumstances, it is 
much better for the beginner to use them upon a 
thoroughly conscious individual. After they are 
once applied there is no reason in the operation itself 



120 HOW TO USE THE FOECEPS. 

why an anaesthetic should be withheld, though I 
would still oppose its use, for reasons foreign to the 
matter in hand, and therefore inappropriate for dis- 
cussion in these pages. Thirdly, the forceps should 
never be taken up with the determination to apply 
and use them " whether or no." The beginner, and 
indeed the more experienced practitioner, will occa- 
sionally attempt to apply them in an unsuitable case. 
If when he finds that a blade does not go on readily 
or that the blades cannot be made to lock, he loses 
his self-control, and dripping with perspiration at- 
tempts to force circumstances and the forceps to 
obey his will, he will surely do damage. Force is 
never needed in their application. If they are passed 
in the right direction they will find their place in 
every suitable case. Gentleness and skill are the 
needed elements, and never force. If these fail, let 
the physician send for some one else, since two heads 
are better than one. Or, if he is remote from assist- 
ance, let him suspend his efforts for a while, medi- 
tate upon the cause of failure, and try again. 
Fourthly, if the blades will not lock readily, it is 
usually the fault of the second blade, which should 
be taken out and reapplied instead of attempting to 
force the blades into locking. If, after due trial, the 
locking is still impossible, both blades may be taken 
oat and reapplied, while the position of the head 
should again be carefully made out, since a mistake 
in diagnosis may have been made, or the position it- 
self may have changed, as occasionally happens. 



TRACTION. 121 



TRACTION. 

The forceps having been applied, the next ques- 
tion is, what are we to do with them ? Are we to 
pull the head out by direct traction, or to pry it out 
by leverage, and shall it be compressed during either 
of these movements ? 

The following propositions may be laid down as 
a starting-point : First. If the Davis forceps (or 
any other having a sufficient pelvic and head-curve), 
are applied to the sides of a head at the inlet in the 
first vertex position, the general line of the blades 
will be parallel to the axis of the presenting plane of 
the head. Secondly. If traction is made in the line of 
the blades, the distal ends of the blades will press upon 
the head, and if the latter is movable will push it on- 
wards in the line of the axis of the presenting plane. 
Thirdly. If during traction the line of the blades is 
kept parallel with the axis of the canal in which the 
head is placed, the axis of the presenting plane of 
the head will be kept in coincidence with the 
axis of the canal in which it moves. This is what 
takes place in normal labor, and this is what it 
should be our aim to imitate with the forceps. It 
ought not to require a mathematical demonstration 
to show that when the head is kept in this exact re- 
lation with the pelvic canal it will move with the 
least possible expenditure of force. If instead of 
this the force be so directed as to push or pull it al» 



122 HOW TO USE THE FORCEPS. 

ternatelj against the sides of the pelvis, more force 
will be required, unless the laws of mechanics are 
altered for the benefit of obstetricians. And yet the 
great majority of obstetric writers recommend that 
traction be supplemented by leverage, and that the 
handles of the forceps should be swayed from side to 
side that the head may be pried out as well as pulled 
out of the pelvis. From this it may be inferred, 
however presumptuous the inference may seem, that 
they do not make traction in the right direction. 
Barnes asserts that " pure traction is almost an im- 
possibility," and this is true enough, if the usual di- 
rections for the use of the forceps are complied with. 
A few selections from authoritative works will be 
sufficient to indicate what these directions are, and in 
what they result. Oazeaux, p. 970, says: " If the 
head is at the superior strait, we must first draw 
downwards and backwards as much as possible." 
But how? " In performing tho tractions the right 
hand is placed near the clams (at the ends), and 
above the instrument, the left hand in front of the 
articulation and beneath." Leishmann, p. 460, 
says : " The handles should be grasped by both 
hands. . . The force should be applied as nearly 
as possible in the direction of the axis of that part of 
the pelvic canal within which the head lies ; and the 
operator should act by combining steady traction 
with a swaying motion of the handles from side to 
side." Playfair, p. 468, says : " When once the 



TEACTION. 123 

blades are locked we may commence our efforts at 
traction. To do this we lay hold of the handles with 
the right hand, using only sufficient compression to 
give a firm grasp of the head and to keep the blades 
from slipping. The left hand may be advantageously 
used in assisting and supporting the right during our 
efforts at extraction, and at a late stage of the opera- 
tion maybe employed in relaxing the perineum when 
stretched by the head of the child. Traction must 
always be made in reference to the pelvic axes, being 
at first backwards, towards the perineum, etc." And 
so on through obstetric literature. From these 
meagre directions we learn that we are to pull upon 
the handles, and at the same time to see that the pull- 
ing is in the axis of the pelvis, " as nearly as possi- 
ble." That it is not possible seems to be quite gen- 
erally suspected. Hence the direction of Meadows, 
p. 224:, " When using curved forceps, we should pull 
less with the handles than with the part of the for- 
ceps between the handles and blades." In which 
case we would insensibly do something else than pull, 
as will be presently alluded to. Hodge also, p. 253, 
hints that, " While the practitioner always keeps his 
right hand on the handles, the left may be variously 
employed, sometimes in front of the shanks, so as to de- 
press the whole head toward the coccyx and perineum, 
then again the fingers may be applied to the head oi 
the child to watch its progress, and eventually to the 
perineum, so as to prevent mischief from laceration, 



124 HOW TO USE THE FORCEPS. 

etc., at the time of birth." But in the directions for 
traction we have only a reiteration of the advice to 
make traction and in the pelvic axis, with the lever- 
age superadded. I have not the slightest doubt that 
the practice of Dr. Hodge was superior to his pre- 
cepts, and Lusk says : " Many indeed seek to pre- 
vent the anterior pressure of the forceps by placing 
the left hand upon the lock and using it as a fulcrum 
around which rotation is effected." Although there 
is no written precept for this, I have seen the forceps 
used rightly by more than one who would have stated, 
if asked, that he was following the ordinary rules. But 
can we, by pulling upon the handles, cause the head to 
move in the right direction ? In Fig. 23 we have a 
representation of the forceps applied to the head at 
the inlet. The line EF indicates in a general way 
the line of the blades and also as nearly as can be 
shown in an antero-posterior section the first direc- 
tion in which the head should move. If we pull 
upon the handles, we will pull in the line of the 
handles, and every part of the blades as well as of 
the head, which is for the moment immovably con- 
nected with the instrument, will move in a line paral- 
lel to the line of the handles. Hence even when the 
handles are well against the perineum and traction 
is made directly downwards, the head will be pulled 
against the symphysis pubis. Practically, it is diffi- 
cult to avoid elevating the handles somewhat, espe- 
cially if the force is great, in which case the head will 



TRACTION. 



125 



be more directly and inevitably pulled against the 
symphysis. Between the head and symphysis will be 
the bladder and cervix uteri, which will suffer more 
or less, according to the amount of force employed, 




Fia 23. 

while the head will not be advanced. Notwithstand- 
ing these facts, there are some teachers who delib- 
erately advocate the most powerful traction with both 
hands upon the handles of the forceps. 

I extract from current medical literature a case 
which shows that this teaching is carried into prac- 



126 HOW TO USE THE FORCEPS. 

tice, and that it sometimes accomplishes delivery. 
The writer has gone to his account. " On the 2d of 
March, I attended to a Mrs. M., a multipara, thhd 
child. The two first were delivered by craniotomy. 
The vertex presenting K. 0. A., and impacted be- 
tween sacrum and pubes ; the Conjugate diameter of 
superior strait greatly contracted. I applied forceps 
and had considerable difficulty in locking them. 
Dreading the laceration which might ensue, in this 
case, from side-to-side lever action, I concluded to 
rely entirely upon direct and steady traction. My 
strength giving way, her husband held me around the 
waist, whilst the patient was held in situ on the dor- 
sum, by four women. In forty- five minutes I had 
the satisfaction of bringing the head down on the 
perineum. The delivery was then speedily accom- 
plished. Both mother and child, a girl, did 
well." This is simply horrible, and yet the child 
was born and the mother recovered. Two circum- 
stances probably determine the delivery When the 
forceps are used in this manner. In the first place 
the head finally slides off from the pubes as from an 
inclined plane. But the amount of force requisite 
for this is very many times greater than that which 
would be required if the traction were made in the 
right direction. In the second place, the head being 
pressed against the cervix, irritates the uterus into 
making powerful contractions, which both impel the 
child in the proper direction and to some extent de- 



TRACTION. 



127 



fleet the tractile force of the forceps. The power 
which the forceps have in determining nterine con- 
tractions by the mere fact of their presence is an im- 
portant fact, and in many cases greatly diminishes 
the amount of force required from the forceps them- 
selves. 

Among the first to have a practicable doubt as 
to the possibility of making traction upon the han- 
dles in the proper direction was Tarnier, who accord- 
ingly invented a pair of forceps with a considerable 
pelvic curve, which was fitted with steel rods affixed 
to the lower edge of the blades, 
so that we could pull in the line 
of the blades and not in that of 
the handles. This is an unne- 
cessarily ingenious contrivance, 
since we possess in the ordinary 
forceps all that is necessary if we 
will use them correctly. 

The method which seems to 
me to be the correct one, I will 
now attempt to describe. When 
the forceps are applied at the in- 
let the handles are seized by the 
right hand from above and held 
firmly, compressing the head as 
little as possible at first. The FlG - 24 - 

left hand is placed so that the ball of the thumb 
comes over the lock (see Fig. 24), while the index- 




128 HOW TO USE THE FORCEPS. 

finger rests upon the upper arm of one blade, and the 
middle finger upon the other. Now, while the right 
hand holds the handles almost at rest, the fingers of 
the ]eft push upon the blades so as to move them and 
the contained head downwards, backwards and a lit- 
tle to the left of the median line. Secondly, while 
the fingers are pushing downwards in this way, we 
may also make use of them as a fulcrum, and by ele- 
vating the handles cause the blades to move in an 
opposite manner, but care must be taken that the force 
thus applied by the right hand is not enough to over- 
balance the downward pressure of the left, else we 
will merely extend the head without propelling it. 
It is sometimes convenient to vary the position of 
the left hand and fingers, but the principle is the 
same, that pushing and not pulling is the first step 
in traction. When the head begins to descend we 
may place three fingers between the blades, the 
thumb and little finger being upon the outside, and 
combine a pulling with a pushing motion upon the 
blades. But throughout the handles are simply ele- 
vated and not pulled upon, or but slightly, having 
due regard to the proper direction, and bringing 
them into the median line only when the head has 
reached the inferior strait. When the head is deliv- 
ered the handles will lie upon the abdomen of the 
mother. This, in brief, is the method which I em- 
ploy and advise. When we consider the compara- 
tively small amount of force which the fingers can 



TRACTION. 129 

exert, it is in marked contrast to the method of em- 
ploying the nnited efforts of two men in pulling upon 
the handles, and will scarcely be credited with suffi- 
cient power by those who are accustomed to use 
much force. But when we reflect upon the state- 
ments of Poppel and Kristeller, that a force of from 
four to eight pounds is often enough to expel a head 
that had lain immovable for hours, it is evident 
that traction in the right direction need not be very 
forcible. For the forceps are used perhaps oftener 
for simple uterine inertia than for any other reason, 
and it is especially in these cases that I recommend 
this method. And it is also evident that traction 
which impels the head against the pubes instead of in 
the proper pelvic axis must always be unnecessarily 
powerful in every instance. "When this method is 
carefully and patiently carried out, it will rarely fail 
to deliver if the case is a suitable one for the employ- 
ment of the forceps. But there are occasionally met 
with cases in which more force is demanded,, in 
which the method must be modified. In such cases 
we may pull upon the handles with the right hand 
and with such force as may or can be exerted, while 
at the same time we endeavor to deflect the force in 
the proper direction by pushing upon the blades in 
front of the lock with the left hand, at the same 
time making use of the leverage above described. 
But under no circumstances will it be necessary to 
pull upon the handles with both hands, or put the 



130 HOW TO USE THE FORCEPS. 

foot against the bed, or secure additional help in 
traction. If the force which can be exerted in the 
right direction in this way is incompetent to deliver 
the child, no amount of force wrongly applied will 
succeed without injuring the maternal tissues to an 
utterly unjustifiable extent. 

Having defined what I mean by traction, the details 
of the operation may be enumerated. The tractile 
efforts should be made during the continuance of 
the labor pains, if the latter are frequent and regular, 
and suspended in the interval between them. But as 
the pains will rarely be of this character, it is usually 
allowable to pay little attention to them. They should, 
however, be imitated, with some exaggeration. Trac- 
tion may be made during one or two minutes, and then 
suspended during two or three minutes. There are 
several reasons for the intermission. In the first place, 
continuous pressure will be undesirable for the mother, 
and will weary her. To give rest between the efforts 
is therefore necessary. Secondly, it either dilates the 
vaginal tissues too rapidly, if we succeed in continu- 
ously advancing the head, or it interferes too nrLch 
with the circulation in the parts in advance of the 
head if the latter does not advance. If the pressure 
is intermittent this is avoided. Thirdly, there will 
be more or less compression of the head in every case. 
If the traction is continuous the compression, what- 
ever its degree, will be continuous and the circula- 
tion in the child's brain will be dangerously inter- 



TRACTION. 131 

fered with as well as that of the parts to which the 
blades are directly applied. For this reason it is ad- 
visable, whenever we have ceased traction tempora- 
rily, to partially or wholly unlock the forceps in 
order to take off all compression exerted by them 
This is done by sliding the female branch partly or 
altogether from under the button of the male branch. 
When we resume traction, the simple grasping the 
handles relocks the instrument, and allows us to pro- 
ceed as before. 

The whole time occupied in traction varies great- 
ly in different circumstances. In a simple case 
of uterine inertia without disproportion, the only 
consideration in the way of immediate delivery 
is the due preparation of the soft parts. Ten or 
fifteen minutes is all that is usually required by 
the multiparous woman for the accomplishment of this 
part of labor naturally, and we may conform to this 
in using the forceps. Where there is much dispropor- 
tion, we may have to wait much longer before we can 
deliver, during which time the head is moulded, as in 
protracted labor without the forceps. I do not think 
that any rule can be laid down as to the longest limit 
of traction. Ellwood Wilson has kept them on for 
eight hours (Am. J. Ob., 1876), using them only dur- 
ing the pains and merely to assist the latter. This 
is an exercise of patience which would overtask most 
of us, and would not be safe as a rule for general ap- 
plication. The duration of the second stage of labor 



132 HOW TO USE THE FOECEPS. 

for eight hours, with the head well in the pelvis, is 
not entirely . devoid of danger, under any circum- 
stances, though when we reflect that the compres- 
sion of the head by the forceps really relieves the 
maternal tissues to that extent, it is probable that 
labor might be allowed to continue much longer 
while the forceps were applied than without them. 
When we find that the head does not advance under 
our efforts, made in the proper direction and with full 
compression, we may decide when to abandon the 
forceps for the perforator by the condition of the 
mother. So long as that continues good and the pel- 
vic tissues show no signs of injurious pressure, we 
may continue our efforts until thoroughly satisfied 
that the head cannot be delivered by the forceps. But 
in the vast majority of cases, if the forceps can be ap- 
plied and locked, they will be competent to deliver, 
under an hour. And it cannot be too often repeated 
that there is nothing to be gained by becoming im- 
patient and hanging with our whole weight upon the 
handles of the instrument. So long as force is ap- 
plied in the right direction, any amount which can 
be exerted may be employed. The safeguard is that 
a great deal of force cannot be applied in the right 
direction, and if it is used in any other direction it 
becomes at once unjustifiable, whatever its amount. 

When the head is upon the perineum, it is some- 
times well to make tractions between the pains, and 
not during .their continuance. This applies mainly 



TRACTION. 133 

when the expulsive efforts are violent, for in that case 
the added force from the forceps will favor perineal 
laceration. This plan was first suggested by the late 
Dr. S. D. Turney, and will sometimes be found use- 
ful. There are some who recommend that the for- 
ceps should be removed when the perineum has be- 
come greatly distended, for fear of laceration. 

The forceps give us such a thorough control over 
the head and its movements that I believe they are a 
great help to prevent rather than to cause this acci- 
dent. We can hold back or advance, flex or extend 
the head with entire ease, as may be needed. But to 
do this successfully requires coolness, judgment, and 
quickness, and a wrong turn of the forceps at the 
critical moment will certainly cause a laceration if 
this is at all imminent. If a person is not quite sure 
of himself, he had therefore better take them off 
rather than wield a power potent for evil as well as 
good. When they are removed the head may be ex- 
tracted by the form of rectal manipulation known as 
the Eitgen-Goodell method, although Smellie (Coll. 
10, cases 1-2) described and used it, and gave the 
credit to Ould. Two fingers are introduced into the 
rectum and placed upon the forehead of the child, 
while the thumb of the same hand, or fingers of the 
other hand, are placed upon the occiput through the 
vulva. The head is then manoeuvred out in a manner 
easier to perform than to describe. When this is 
done during the absence of a pain we certainly escape 



134 HOW TO USE THE FOECEPS. 

from rupturing the perineum, so far as the head is 
concerned. 

In taking off the forceps when the head is on 
the perineum we consider mainly the head-curve 
of the instrument. Having separated the lock, one 
of the handles is moved across the median line so as 
to lie in the groin of the opposite side, which will 
cause the blade to glide out of the vagina without dis- 
turbing the head at all. The same is done with the 
opposite blade in the contrary direction. When for 
any reason it becomes necessary to remove the for- 
ceps at a higher level, the pelvic curve may have to 
be considered, or in other words the blades are with- 
drawn in the same manner in which they are applied, 
with a reversal of direction. 

COMPKESSIOI*. 

The utility of the forceps as a compressor is 
beyond question, since the bi-parietal diameter is 
capable of being diminished by their use from a 
half inch to an inch. As we can reduce the antero- 
posterior diameter in another way, we can by com- 
pression greatly facilitate delivery. But when the 
forceps are not applied to the sides of the head we 
must be very careful how we use compression on the 
living child. The question in such a case is not so 
much whether we can diminish the size of the head 
by compression, but whether we will not cut and in- 
jure the head by it. When applied to the sides of 



LEVERAGE. 135 

the head, and this should include the great majority 
of cases, compression carefully performed is entirely 
innocuous and of great benefit. It should in every in- 
stance be performed slowly, evenly, and gently, and 
should be maintained only for a minute or two at 
most, with an interval of relaxation following. If 
the head is suddenly squeezed in the forceps, or if the 
handles are tied together, as the manner of some is, 
harm will be done as a matter of course. But if ef- 
fected as stated above, the full compressing power of 
the instrument may be exerted without injury to the 
child. I have been surprised to find after the fullest 
compression, but intermittently applied, that not 
even a temporary imprint of ihe blades could be dis- 
covered upon the child's head within ten minutes af- 
ter its delivery. I do not think that anything is ever 
gained by continuous compression. The head can 
be moulded to much better advantage, even in the 
most difficult cases, by systematically intermitting 
both traction and compression, even when the ques- 
tion of the child's life is not under consideration. 

LEVERAGE. 

The action of the forceps as a lever may be in- 
voked in some cases, for the purpose of flexing or 
extending the head, but I hasten to add that it is 
not to be used to pry out the head by " to and 
fro ' ' leverage, as is so generally taught. Denman, 
p. 376, recommended to use the forceps almost 



136 HOW TO USE THE FOKCEPS. 

exclusively as a lever. " The first action with them 
should therefore be made by bringing the handles, 
grasped firmly in one or both hands, to prevent the 
instrument from playing upon the head of the child, 
slowly toward the pubes, until they come to a full 
rest. Having waited a short interval with them in 
this situation, the handles must be carried back in 
the same slow and steady manner to the perineum, 
exerting as they are carried in the different direc- 
tions, a certain degree of extracting force ; and after 
waiting another interval, they are again to be raised 
toward the pubes according to the situation of the 
handles." As this would only alternately flex and 
extend the head, as well as interfere with any right 
direction of traction, it is no wonder that Denman 
preferred the vectis, about the use of which he ap- 
pears to have had a more intelligent understanding. 
The more modern method is known as the " pendu- 
lum leverage" or " lateral oscillations," and consists 
in swaying the blades from side to side while making 
traction. This is supposed to act on the principle of 
the ratchet. One side of the head is brought down 
and is expected to stay down while by a reversal of 
the instrument the other side is brought to the same 
or a lower level, and so on until it is extracted. 
Barnes claims to be able to deliver in this way al- 
most without any traction. Even if it were true 
that this method of leverage was preferable to trac- 
tion in the pelvic axis, and advanced the head, it is 



LEVERAGE. 



137 



^ mUb 



pertinent to inquire how this is effected. If it is 
done at all, it must be by making each side of the 
pelvis alternately a fulcrum, against which the for- 
ceps are pried. As J. Matthews Duncan says, there 
is no toothed rack in the pelvis. Therefore, when 
we bring down one side of the head we must press it 
with great firmness against the pelvic walls if we ex- 
pect it to retain its position while the other side of the 
head is being brought down. In other words, the steel 
blades of the forceps or the parietal protuberances are 
alternately jammed against the maternal tissues inter- 
vening between them and the pelvic walls upon each 
side whenever this delectable 
form of leverage is resorted to. 
And this happens whether the 
head really is advanced by it or ^ 
not. That it does not advance 
the head seems to me to have 
been so clearly shown by Dr. 
A. H. Smith that I take the 
liberty of quoting largely from 
his paper (Fig. 25). " Let PW 
and P'W be the pelvic walls 
in section made in the plane of 
the maximum diameter, and of 
that transverse diameter, the 
ends of which are grasped by 
the blades. Let MM' be the 
maximum diameter, corresponding with the axis 




Frc 25— After A. H. Smith. 



138 HOW TO USE THE FORCEPS. 

of the canal, GD the transverse (whether bi-parietal 
or other) these two crossing each other at A, which 
will then be the centre of oscillation of the head in 
any pendulum movement of the handles and the cen- 
tre of motion in a direct traction. Let us draw 
through this centre two oblique diameters, 00, OC, 
and also from the extremity of the line GD an 
oblique line to a point 0, on the periphery of the 
head nearer to M ; . FBB' will represent the blades 
of the forceps through the fenestra of which the tis- 
sues of the scalp should protrude sufficiently to rest 
firmly against the pelvic walls, unless the blades be 
narrow, when the scalp tissue will come in contact 
with the pelvis at the sides of the blades. . . . 
AVhat will be the effect of pure oscillation, or leverage 
as it is called, with compression, but without trac- 
tion, the method recommended by Dr. Barnes ? The 
first movement, say, will carry the handles toward W ; 
the head, then, being ' immovably united to the for- 
ceps,' must rotate upon an axis passing through A, 
perpendicular to the transverse GD, which transverse 
also rotates, the extremity G moving upward toward 
P, and the extremity D correspondingly descending 
toward W. But as the diameter GD moves, so does 
the oblique diameter 00, passing through A, move 
also proportionally ; C following G upward, as fol- 
lows D downward, and the extremities of this oblique 
diameter come to assume the position, in relation to the 
Diane of the pelvis occupied before this lateral move- 



LEVERAGE. 139 

ment, by the extremities of the transverse diameter. 
But we know that every oblique diameter of an ovoid 
passing through the centre of the greatest transverse 
diameter is greater than the transverse, and that the 
increased length is proportionate to the distance of its 
extremities on the periphery from those of the trans- 
verse. The more considerably, then, we move the 
handles towards W, the more we place the longer di- 
ameter of the head in the position originally occu- 
pied by the transverse diameter. As the handles 
swing back, approaching the median line, the diam- 
eter in relation with the plane diminishes until the 
handles pass the median, and are made to approach 
W ; when the same change takes place in the bearing 
of the extremities of the oblique diameter O'C, and 
this diameter takes the place of the transverse against 
the pelvic walls. Here, then, we have a demonstra- 
tion sufficiently clear . . . that oscillation with- 
out traction simply brings to press upon the pelvic 
walls, with a sort of slow vibratory impact, portions 
of the head farther separated from each other than 
the points which rested in contact with those walls 
before the swaying motion was started ; that while 
the pelvic wall is subjected to alternations of exces- 
sive pressure and partial relief, there is nothing in 
the movement itself to advance the head an iota, the 
side which descends with the swaying of the handles 
in one direction, ascending equally (unless driven 
down by the vis a tergo, which acts altogether inde- 



140 HOW TO USE THE FOKCEPS. 

pendently of it) when the handles are swayed in the 
opposite direction. " 

In the same manner he demonstrates that 
" leverage with traction is simply traction plus 
an aggravation of pressure upon surfaces already 
so tightly compressed by the circumference of the 
child's head as to obstruct its advance toward the 
outlet of the pelvis. ' ' As I have already shown, the 
proper direction of traction at first is not in the 
median line, but somewhat to one side, in the axis of 
the canal in which the head is placed. With every 
other lateral oscillation therefore, the head is so far 
forth impelled by the coincident traction in that axis, 
which may account for the success in delivery which 
is claimed for this method. But it is hardly neces- 
sary to add that it is not expedient to subject the 
mother's tissues to pressure for the sake of occasion- 
ally making traction in the right direction, when it 
is equally easy to make it directly and uniformly in a 
proper manner. 

The forceps have a proper use as a lever ; first in 
flexing the head. 

a, Flexion. — A delay in the flexion of the head may 
be and not infrequently is the sole cause of delay in 
the advance of the head. We may, in such a case, 
apply the forceps and by simple traction deliver, but 
as the occipito-frontal diameter is thus kept coinci- 
dent with the successive pelvic planes, unless the 
head is spontaneously flexed in transit by the influ- 



LEVERAGE. 141 

ence of the pelvic walls, a greater amount of force is 
required to deliver than if the cervico-bregmatic di- 
ameter had been substituted. Preliminary flexion 
of the head is therefore very desirable. If the head 
is not flexed the blades of the forceps are not parallel 
to the occipito-mental diameter of the head when ap- 
plied, which should be the case when the head is thor- 
oughly flexed. After applying them in such a case, 
then, before thoroughly locking the instrument, 
we may elevate the handles. This will allow the 
blades to glide over the head and become parallel to 
the occipito-mental diameter. We then slowly and 
firmly compress the head with the handles in this 
position, and when the head is thoroughly grasped 
we return the handles to their original position, press- 
ing against the perineum, at the same time pushing 
them gently farther into the pelvis in order to slight- 
ly lift the head from the brim while the movement is 
being made. This will flex the head, so that in some 
cases the amount of force required for extraction will 
be very slight, if indeed, the uterine efforts are not 
entirely sufficient. This manoeuvre in competent 
hands is devoid of danger, but the blades must be 
upon the sides of the head, and we must, of course, 
accurately know the position of the head before at- 
tempting to change it. 

In occipito-posterior positions the same principle 
may be brought to bear with great advantage. The 
rotation of the occiput forward is promoted by ex- 



142 HOW TO USE THE FOKCEPS. 

treme flexion. At the very beginning, we then, may 
secure this in the following manner : The handles 
are pressed back firmly against the perineum, as each 
blade is introduced. The head is then carefully 
grasped and the handles elevated. Traction is then 
made with the handles in an elevated position in 
order to keep the head flexed as much as possible. A 
similar elevation of the handles is sometimes useful 
during the perineal stage of an occipito-anterior posi- 
tion in order to extend an unduly flexed head. The 
application of the same principle in facial positions 
is sufficiently obvious, as well as in a condition of too 
great lateral obliquity in the vertex positions. As 
compression reduces the bi-parietal diameter, and 
flexion shortens the antero-posterior diameter, the 
combination of the two procedures decreases the en- 
tire circumference of the head. 

i, Rotation. — It is also possible to use the forceps 
to rotate the head, but this application of the instru- 
ment is rarely proper or useful. In occipito-anterior 
positions the pelvic walls will effect rotation much 
better than we can, if we are careful to make the trac- 
tion in the right direction. All we need do is to see 
that we do not hold the handles in such a manner as 
to interfere with rotation. But in occipito -posterior 
and mento-posterior positions the desirability of 
early anterior rotation is so apparent that there is a 
strong temptation to bring it about with the forceps at 
all hazards. In these positions, when the head is at 



LEVERAGE. 143 

the inlet, it is highly improper to attempt anterior 
rotation with a pair of forceps having a decided pel- 
vic curve. The form of the instrument distinctly 
prohibits this. 

The voice of experience is equally clear against 
making the attempt with the straight forceps. If 
then we cannot secure anterior rotation by manipu- 
lation, either internal or external or both combined, 
we may apply the forceps to the sides of the head as 
it lies and make traction in the axis of the canal in 
which it is placed without any present reference to 
its rotation. We should exert as little compressing 
force upon the head as possible, for this reason. 
When the head nears the inferior strait it tends to 
undergo anterior rotation according to a mechanism 
described in a preceding section. As the parietal 
protuberances project through the fenestra of the 
blades the mere presence of the forceps does not in- 
terfere with this, and anterior rotation may take 
place by the head turning inside the blades of the 
forceps. This has not unfrequently been noticed. 
Decided compression tends to allow the head to come 
down without sufficient contact with the pelvic walls 
to compel rotation, especially if the tractile force is 
considerable at the same time. The fact of its oc- 
currence will be generally indicated by a tendency of 
the blades to slide together posteriorly, when the for- 
ceps are unlocked in the intervals of traction. For 
as a uterine contraction comes on, before the forceps 



144 HOW TO USE THE FORCEPS. 

are locked the head, in attempting to rotate, carries 
one of the blades with it, leaving the other station- 
ary. This at least is the explanation I have framed 
from observing the phenomena, though it is not en- 
tirely adequate. For under these circumstances it 
may happen that as soon as the forceps are unlock- 
ed, and when there is no uterine contraction, the pos- 
terior edges of the blades at once approximate, which 
perhaps shows that during the last traction the head 
was prevented from rotating anteriorly by the man- 
ner in which the forceps were held ; but as soon as 
it is released from their influence it rotates, carrying 
one of the blades with it. If the position of the 
blades is not much altered they may be carefully 
made to come opposite to each other without with- 
drawing them, but if their relative position is much 
disturbed, it is an evidence that anterior rotation is 
nearly or quite complete, and they may be withdrawn 
and re-applied as in an anterior position. I have 
witnessed these changes taking place during the de- 
scent of a mento-posterior position, and have re-ap- 
plied the forceps accordingly. The innocuousness 
of the proceeding was shown by the fact that not 
even a temporary imprint of the blades was discover 
able upon the head immediately after birth. If the 
head is large it will not rotate within the forceps, 
but may rotate with them. It is in just such cases 
that it seems most plausible that we should force an- 
terior rotation with the instrument. For if it fails 



LEYEKAGE. 145 

to occur we will have to drag the occiput over the 
perineum, or in the case of the mento- posterior posi- 
tion be utterly foiled in the delivery. Nevertheless, 
forced rotation will almost invariably prove to be a 
meddlesome interference. And although the situa- 
tion seems to call for the limit of tractile force, we 
should also be very chary of this as well. 

If traction is very powerful at this juncture, com- 
pression will almost certainly be also carried to its 
extreme limit, and we may pull the head through the 
inferior strait posteriorly and destroy all hope of an- 
terior rotation. What is needed is moderate and 
patient traction, and a slight motion of rotation ; so 
slight as to be of little service for effecting a change 
of position in itself and only to test the inclination 
of the head. If the head is manifestly inclined to 
rotate it may be gently assisted, but force will do no 
good and may do harm. The head and the pelvic 
walls between them will determine the exact level 
and time at which rotation can be effected much bet- 
ter than we can, and we should therefore only assist 
it when actually being performed and not prema- 
turely urge it. When the head is at the inferior 
strait so much of the blades are exterior, that the 
intra-vaginal portion of the instrument is sufficient- 
ly straight to make it entirely proper to allow the ro- 
tation to take place with the forceps applied. But 
when it has occurred they should be withdrawn, 
when they may be re-applied, or the case left to the 



146 HOW TO USE THE FOKCEPS. 

uterine contractions. There are two principal rea- 
sons for not attempting to force rotation. In the 
first place rotation is normally accompanied by de- 
scent. The head begins to rotate at the level of the 
ischial spines, but at the end of the movement may 
have reached the perineum. 

The exact proportion of descent and rotation in a 
given case is determined by circumstances which we 
know nothing about in a given case, and not even a 
skilful operator can cause the head to rotate anteri- 
orly as well as the natural conditions spontaneously 
bring about. On the contrary he may impede the 
process by his efforts. In the second place, a cer- 
tain proportion of cases cannot be rotated ante- 
riorly without twisting the neck of the child to a 
fatal extent, and doubtfully even then. When the 
back of the child's body is posteriorly situated in 
the womb this is true, and this cannot always be 
known beforehand or remedied by manipulation. 
To patiently make moderate tractions in such a way 
as not to interfere with rotation, and to keep the 
head well flexed, should be our aim in occipito-pos- 
terior positions. 

WHEN TO USE THE FORCEPS. 

The forceps may be used under the following cir- 
cumstances. 

I. For delay in the second stage of labor, arising 
from : a, uterine inertia ; d, small size of vagina ; c % 



WHEN TO USE THE FORCEPS. 147 

rigidity of maternal tissues ; d, obstructions from 
bands, etc. ; e, large size of head ; /, want of flexion ; 
g, pelvic deformity. 

II. For delay in the first stage occasionally, as in : 
a, placenta previa ; S, rigidity of the os uteri ; c, 
absence of a natural dilating agent. 

III. For certain accidents of labor, in any stage, 
and when rapid delivery is indicated, as °. a, convul- 
sions ; ~b, prolapse of the funis ; c, excessive uterine 
action menacing rupture. 

IV. For certain secondary purposes as for : a, 
extraction of the child after rupture of the uterus ; 
h, after gastro-hysterotomy or elytrotomy ; c, for re- 
moving tumors and foreign bodies from the maternal 
passages. 

The forceps have been and may be used for any of 
these conditions, though the advisability of their use 
in a given case must depend upon the individual cir- 
cumstances then present, and not entirely upon a 
general rule. 

I. It is first" in order to define what is meant by 
delay in the second stage, or what measure of delay 
calls for the use of the forceps. 

"When the os uteri has become fully dilated and 
the liquor amnii has escaped, the great majority of 
multiparous women are delivered within a few min- 
utes, A second stage of five or ten minutes' dura- 
tion is very frequently observed and fifteen minutes 
is probably above the average in normal labor. In 



148 HOW TO USE THE FORCEPS. 

primiparse, the dilatation of the vagina and peri- 
neum usually takes up more time, so that from a half- 
hour to an hour is not far from the average in this 
class of cases. The length of the first stage has little 
to do with that of the second. A first stage of 
twenty-four hours may be followed by delivery in ten 
minutes, when once the os uteri is dilated, and a first 
stage of two hours may be followed by a second stage 
of many hours. The second stage may be protracted 
from any of the causes mentioned under this head at 
the beginning of the section, the most common of 
which is uterine inertia, or a want of sufficient pro- 
pulsive power, for the term is a rather relative one. 
If the case is protracted beyond the average limit 
we may ask ourselves three questions : First, What 
harm does the delay do ? Second, Can we safely inter- 
fere ? Third, Of what advantage to either the mother 
or child will the leaving the case to " Nature " be ? 
First. Delay in labor, especially in the second 
stage, injures the mother and child in direct propor- 
tion to the length of its continuance and the depth 
to which the head has descended in the pelvis. Each 
expulsive effort is attended with an expenditure of 
vital force, while at the same time the functions of 
digestion and assimilation are so interfered with that 
the drain cannot be kept up indefinitely. The 
woman is weaker with each pain. This is pro- 
vided for in normal labor. The ideal woman during 
an ideal pregnancy becomes more robust and vigor- 



WHEtf TO USE THE FOKCEPS. 149 

ous during the whole gestation. She enters upon 
labor with a reserve of physical force entirely ade- 
quate for its performance, so that when delivery is ac- 
complished she may arise, cleanse herself and the 
baby, and resume the ordinary functions of life with 
unimpaired vigor. But the ordinary civilized wom- 
an with whom we have most to do, finds even an 
ordinary labor a rather exhausting piece of work, 
and if it is at all long she requires a proportionately 
longer time in which to recuperate. Also, the aver- 
age woman does not only approach labor with a very 
slight, if any, reserve of physical force, but is too 
often even below par at this time. Her urine is apt 
to be albuminous, her blood hydremic, her digestion 
impaired, and if she is, under such circumstances, 
subjected to a long and tedious labor, she is in a ripe 
condition for all the diseases incident to the puer- 
peral state. So far, then, as the expenditure of 
vital force is concerned, the sooner the woman is 
through with her labor the better. She is not only 
using up her strength by muscular contractions, but 
she is kept in mental suspense, and is not usually 
able to repair her energies by the taking of food. 
The continuance of the second stage also involves the 
pressure of the head of the child against the soft tis- 
sues of the mother, with an increase of the pressure 
during each pain. This pressure is least when the 
head is movable at the inlet, but increases in its ca- 
pacity for evil at least, with each fraction of descent. 



150 HOW TO USE THE FOKCEPS. 

Its continuance may result in destroying the vitality 
of the tissues pressed upon. It is the most common 
cause of vesico -vaginal and other fistulas and pre- 
disposes to the occurrence of pelvic inflammation 
after lahor. When the head is long detained at the 
inlet the anterior lip of the cervix is apt to become 
©edematous, which may occur to such an extent as to 
make it a further impediment to delivery. When 
the head is long detained at the inferior strait, or on 
the perineum, the latter structure often becomes 
boggy and inelastic, and is very apt to become lacer- 
ated subsequently. The irritation caused by the 
pressure of the head upon these structures, which are 
delicate and amply supplied with nerves, is apt to 
give rise to convulsions. The child's life is also en- 
dangered, especially when the detention is at a low 
point, for not only is the direct compression harmful 
but the uterus may grind off the placenta and thus 
destroy the child. That all these evils follow in the 
train of delay is universally conceded ; but to come 
to an agreement upon the time when the danger is 
imminent rather than prospective is more difficult. 
Before attempting to fix the danger line we may pass 
to the second question, " Can we safely interfere?" 
This depends upon the questioner. If he is ignorant 
of the anatomy and physiology of the structures in- 
volved, of the mechanism of labor, and of the nature 
of the forceps, he ought not to interfere even by 
his presence. But any one who is really qualified 



WHEN TO USE THE FORCEPS. 151 

to attend upon the parturient woman can interfere 
with perfect safety to mother and child. 

The mere application of the forceps contains not 
a single element which is detrimental, and is not 
even painful. After the} 7 are applied they can hard- 
ly be said to touch the mother during traction, since 
the opposed surfaces of the head project through the 
fenestra. It is not therefore the forceps, but arti- 
ficial traction, which is to be found fault with if the 
operation is objected to. The woman is unable to 
expel the child, for a want of expulsive power. We 
supply this power and the woman is delivered speedily 
instead of waiting indefinitely at great expense of vital 
force. Statistics are not always reliable, and I refer 
those who put their trust in them to papers by Ed. 
S. Dunster* and A. M. Fauntleroy,f merely citing 
one specimen. In the Rotunda Hospital, Collins 
used the forceps only once in 694 cases of labor, with 
a foetal mortality of 1 in 26 and a maternal mortality 
of 1 in 329. Harper used them once in 26 cases, 
with a foetal mortality of 1 in 47 and a maternal mor- 
tality of 1 in 1490. The average duration of labor 
was, in the first case, 38 hours, in the second, 16 
hours. Barnes (Obst. Oper., p. 280) says : " Properly 
speaking, the mortality from the forceps is nil. 
Women die because the instrument is used too 
late/' 

* Proceedings of Michigan State Medical Societ}', 1878. 
f " A.merican Journal of Obstetrics," January, 1879. 



152 HOW TO USE THE FORCEPS. 

We gain further light from the answer to our 
third question, " Of what advantage will it be to 
leave the case to Nature ?" The usual answer is, 
that we avoid the dangers of rapid delivery, allow the 
maternal tissues to be properly " prepared," and 
lastly, we leave the case in the hands of " Nature," 
who or which is all-competent and of benign ten- 
dencies. It is difficult to deliver with the forceps in 
less than ten minutes in any case, and thousands of 
women are naturally delivered in less time. The 
operation usually excites uterine contractions, and as 
a matter of fact, post-partum hemorrhage is rare 
after a forceps delivery, even when they have been 
applied on account of uterine inertia. And in the 
matter of preparation, when the labor has continued 
for an hour or so during the second stage, the tissues 
will be progressively unprepared and unfitted for de- 
livery the longer it continues. A head stationary 
in the pelvis, at any point, is progressively congest- 
ing and infiltrating the tissues below it, and not pre- 
paring them. If it is not stationary, but is advanc- 
ing with each pain, the pelvic canal is so short that 
there will be no delay. The truth is, that refuge is 
taken in a vague appeal to the powers of Nature by 
those who are too indolent to learn how to render as- 
sistance to the mother. In the words of the late Dr. 
Turney, " It sounds well to talk of trusting to Na- 
ture. It is sweetly suggestive of green fields, of 
flowery meads, of singing birds, of the gentle lullaby 



WHEN TO USE THE FOECEPS. 153 

of breeze and falling waters, and brings to mind all 
the pleasant sights and sounds which amuse us in a 
summer's ramble. " But what are the facts ? Nature 
has ordained that woman shall be safely delivered in a 
few hours. The defiance of the laws of Nature for 
generations has brought it about that the woman is 
unable to deliver herself without undergoing great 
danger. And if we were to leave all cases to Nature 
a great many women would die undelivered under 
this benign regime. It is not to Nature that we 
leave the woman, it is to the consequences of physi- 
cal deterioration incurred in defiance of her laws. I 
cannot see what advantage there is in this, when we 
possess safe and efficient means for rescuing her and 
the child from these consequences. 

The logical deduction to be drawn from these 
premises is, that when the os uteri is fully dilated, 
the child should be expelled promptly ; and in the 
time observed to be usually consumed in normal la- 
bors. If it is not, the longer the labor continues the 
more danger the woman and child incur, and con- 
versely, the sooner she is delivered by the forceps, 
the less risk will they run. While these deductions 
are fully warranted by the physical facts involved, 
they are subject to modification from certain consid- 
erations of a practical character. Many women have 
a horror of " instruments " and " operations, " and 
will be unfavorably agitated by the early suggestion 
of their employment. Also, in the existing state of 



154: HOW TO USE THE FORCEPS. 

lay intelligence, if anything whatever should go 
wrong with the woman after their employment, the 
physician and his forceps will have to shoulder the 
blame. On the other hand, Cazeaux mentions that 
the pains of women are sometimes greatly increased 
by the statement that the forceps must otherwise be 
used. Having due regard to these considerations, 
the following rule seems to me to be proper. 

Whenever the second stage of labor has lasted 
two hours and the head is still stationary or advanc- 
ing with great slowness, we should inform the patient 
that we are about to apply the forceps. If we ex- 
plain the necessity and propriety of the operation we 
will rarely find any objections, especially if the 
woman is already tired of her fruitless sufferings. 
This rule may be deviated from according to the cir- 
cumstances of each case, but it will more often be 
proper to shorten it than to protract the time of 
giving relief. There is no need of keeping the 
woman in suffering for hours solely that she may de- 
liver herself, and still less for keeping her under the 
noxious influence of an anesthetic for hours, when 
we can safely extract the child at will. 

These remarks apply to all cases of delay in the 
second stage of labor, but it is necessary to qualify 
them in some particulars. Thus, in obstruction 
from cicatrical bands, persistent hymen, and the like, 
it may be necessary to incise the obstructing mem- 
brane before applying the forceps. More often, we 



WHEN TO USE THE FORCEPS. 155 

may wait until the band is made tense by the pres- 
sure of the head within the forceps, against it, before 
dividing it. A head which is enlarged from hydro- 
cephalus can rarely be delivered by the forceps as well 
as by a preliminary evacuation of the fluid. But the 
forceps are useful as an aid to diagnosis in hydroce- 
phalus, since the large size of the head is very clear- 
ly demonstrated by the wide divergence of the han- 
dles when the blades are applied. And if the head is 
very large the forcep scannot be applied at all. 

In deformities of the pelvis the propriety of 
applying the forceps has been brought in ques- 
tion, and a few words of justification are in order. 
The pelvis is rarely deformed throughout its 
whole extent, the deformity being usually limited to 
either the outlet or inlet. When the outlet is de- 
formed either by the approximation of the ischia or 
bending forward of the coccyx, the propriety of 
using the forceps is unquestioned. But when the 
deformity is at the inlet and is at all considerable, 
many prefer version to the forceps. Barnes says (op. 
cit. p. 244) that the proper range of the operation of 
turning is from 3.25 " to 3. 75 "of the conjugate diam- 
eter, at the latter point coming into competition 
with the forceps. Groodell substitutes version for 
the forceps when the conjugate diameter is between 
2.75 and 3.25 inches. The limit is variously stated 
by different authors, but is recognized by the great 
majority as at least equal to the forceps in marked 



156 HOW TO USE THE FORCEPS. 

deformities and often succeeding when the latter 
have failed. 

The principles upon which this practice rests 
were first stated by Simpson. They are, in brief, as 
follows : First, the transverse diameter of the head 
can be lessened to a greater degree by the influence 
of the pelvic walls when the base of the skull is in 
advance than by the forceps when the head comes 
first. Second, a greater amount of force can be 
employed by pulling upon the body and neck of the 
child, combined with supra-pubic pressure, than by 
the forceps. 

Traction upon the body of the child is ca- 
pable of greatly compressing the head. Of this 
there is no doubt. It can be exerted to the extent 
of producing deep indentations in the parietal bone 
by pressure against the promontory. But it has its 
limits. Duncan has shown that on an average the 
child's neck breaks with a force of 100 pounds and 
decapitation ensues when the force reaches 120 
pounds. We have then a distinct limit to the 
amount of force which can be exerted by traction 
after version. The same experimental data are want- 
ing for the forceps, but all the force which they can 
exert will not affect the integrity of the foetal struc- 
tures, and there is every reason to suppose that a 
force of over 120 pounds can, if necessary, be 
brought into requisition. The main question is 
whether it is true that the bi -parietal diameter can 



WHEN TO USE THE FORCEPS. 157 

be diminished to a greater extent when the base of 
the skull is in advance. 

It is alleged that the base is much narrower than 
the upper part of the skull, the bi-mastoid diameter 
being from four to nine lines less than the bi-pari- 
etal. Hence, when the vertex comes first, the head 
tends to flatten out, while when the base comes first, 
the diameters are progressively diminished during 
its progress. This is true enough, but we should 




Fig. 26. 

contrast the state of affairs in version, not with those 
obtaining in uuassisted vertex labors, but when the 
forceps are used. Which has not been fairly done. 
Fig. 26 represents a transverse section of the foetal 
cranium. When the base is in advance the com- 
pressing force of the pelvic walls will act in the lines 
indicated by the arrows A A. But when the forceps 
are applied to the sides of the head they exert their 
compressive force in the lines BB, or directly. To 
say that the parietal bones may be made to overlap 



158 HOW TO USE THE FORCEPS. 

at C by forces acting in the lines A A, better than 
when acting in the lines BB, is absurd. 

Thus we are driven to the conclusion that version 
cannot be superior to the forceps, or an elective sub- 
stitute for it, when it is possible to apply the forceps 
to the sides of the child's head. The difficulty of so 
applying them has been, I think, greatly exagger- 
ated. The deformity usually occurs upon one side 
only of the pelyis, i.e., one sacro-iliac symphysis 
only has been affected by disease. As the result, 
one of the pelvic canals is impaired or destroyed, but 

the other is not necessarily in- 
terfered with. Such a state of 
things is shown in Fig. 27, from 
Schroeder. Bat when the con- 
Fig. 27. j u g a te diameter is reduced to 3 

After Schroeder. inches Or leSS, both of the Canals 

are impaired and the normal mechanism is entirely 
altered. I admit that the difficulty of grasping the 
head in its bi-parietal diameter increases with each 
degree of contraction below 3 inches, but we can at 
least place them obliquely upon the head in every 
instance. When this is done, we can bring to bear 
upon the head the compressing force of the pelvic 
walls nearly as well as when it is dragged down with 
the base in advance, and without the risk of breaking 
the child's neck, or any of the unavoidable dangers 
attendant upon delivery by the breech.* And in ad- 
dition we will have such compressing and moulding 




WHEN TO USE THE FORCEPS. 159 

power as is afforded by the forceps. Nevertheless, if 
in any case we find it impracticable to apply the for- 
ceps to the sides of the head, we would be justified 
in resorting to version, if the latter were a generally 
safe procedure. Since head-last labors have a mor- 
tality to the child of at least fifty per cent, and since 
version is attended with decided danger to the 
mother, especially when performed through a con- 
tracted inlet, and also since when it fails we have to 
resort to craniotomy at a great disadvantage, this 
cannot be claimed. I cannot then conceive of a case 
in which version is justifiable as an elective procedure. 
If it fails, nothing remains but craniotomy. If after 
applying the forceps we have not enough skill to de- 
liver, then perhaps version may be tried before the 
last resort. 

The manner of using the forceps in a deformed 
pelvis differs but little from that which is appropri- 
ate in the normal pelvis, and that little will be dif- 
ferent in each case because scarcely two deformities 
are exactly alike. One general feature has been 
pointed out by Barnes, viz., that the promontory of 
the sacrum usually projects and the head has to 
make a curved progress around the promontory be- 
fore it can enter the axis of the pelvis, which he calls 
the " false curve of the promontory." The effect 
of this forward jutting of the promontory I conceive 
to be simply to equally push forward the head and 
greatly exaggerate the backward direction of the 



160 HOW TO USE THE FORCEPS. 

pelvic axis. Hence it is often useful to begin our 
efforts at extraction in these cases by pushing the 
whole instrument downwards and backwards in the 
direction of the sacro- coccygeal junction, without 
any traction in the ordinary sense of the term. The 
exact nature of the deformity cannot always be made 
out at the time of labor, but we can always form a 
correct idea as to the direction in which the head 
ought to move in order to pass the narrowed inlet. 
When this is carefully ascertained, we will find that 
a comparatively slight amount of force is often 
enough to bring the head past the obstruction, after 
which it usually progresses without further hin- 
drance. It is worth while spending any amount of 
time in being certain as to the axis in which the head 
is to move, for traction in the wrong direction will 
be tenfold more useless in a deformed than in a nor- 
mal pelvis. 

II. It is sometimes proper to apply the forceps 
during the first stage of labor, or before the os uteri is 
fully dilated. But although we have advanced in 
the obstetric art far beyond the point when a delay 
of at least six hours upon the perineum was regarded 
as an essential prerequisite to their application, a de- 
gree of conservatism is necessary upon this point. 
For there are some unavoidable dangers attendant 
upon their use during the first stage, and the neces- 
sity for their employment should evidently counter- 
balance these before we resort to them. These dan- 



WHEN TO USE THE FOKCEPS. 161 

gers are, first, the possibility of bruising the cervix 
during the introduction, which in skilful hands may 
be reduced to a minimum ; and, second, the proba- 
bility of lacerating the cervix when we come to mak- 
ing traction and cause the head to be pressed against 
it. For this there is no avoidance except in imitating 
the natural course of labor in making the traction 
moderately, intermittently, and patiently, so that the 
head may evenly and with as little haste as possible 
dilate the cervix before passing through the os. And 
yet in the very cases in which the procedure is most 
likely to be demanded the cervix is most indisposed 
to dilate without laceration. 

The fact that a laceration once begun may extend 
indefinitely and end in a veritable rupture of the 
womb, makes this consideration too important to be 
lightly passed over in deciding upon the use of the 
forceps in the first stage. The indications which 
suggest their employment are as follows : First, long 
delay due to the existence of organic rigidity of the 
cervix. The most notable case illustrating this use 
of the instrument is one reported by Roper, 1874, in 
which the cervix was four inches long and as thick 
as a man's wrist. After labor had lasted forty hours, 
seven incisions were made, and gradual dilatation al- 
lowed to proceed for sixteen hours, after which the 
forceps were applied and a living child extracted. 
This is an extreme case, but the principles of 
treatment are the same in lesser degrees of organic 



1()2 HOW TO USE THE FORCEPS. 

rigidity. First, incision, which should not be de- 
ferred so long as in this case ; second, a brief period 
for further dilatation by the natural powers, and 
then, or indeed as soon as the forceps can be ap- 
plied, they may be used to further the dilatation by 
increasing the force with which the head is pressed 
against the cervical rim. If incisions are unneces- 
sary, so much the better, but in true organic rigidity 
they are usually demanded. The greatest care and 
gentleness is called for during traction, which if at 
all sudden or violent, would be sure to do harm. In 
this way we bring a more efficient dilating force to 
bear against the cervix than in any other possible 
way. The fact that traction must be made with 
moderation, and will probably last for some time, is a 
valid reason for resorting to it early in the labor. 
We must not wait until the woman is exhausted by 
her efforts before we begin, or the desperate nature 
of the circumstances will impel us to work faster 
than we know to be judicious. 

In functional or spasmodic rigidity of the cervix, 
which has resisted other methods of treatment, it is 
also allowable to apply the forceps as soon as they 
can be introduced without violence. There are also 
certain cases in which the liquor amnii is early eval- 
uated and the head of the child fails to take the 
place of the bag of waters as the natural dilating 
agent. In cases of unusual pelvic or uterine obliq- 
uity, or when from any cause the head is not forced 



WHEN TO USE THE FORCEPS. 163 

against the cervix after the evacuation of the liquor 
amnii, the os fails to dilate. In these cases we will 
usually find that the cervix is early dilatable al- 
though undilated, and if by external or other manip- 
ulation the head cannot be made to engage, it is 
proper to apply the forceps, since otherwise the sec- 
ond stage is not likely to begin. 

The duration of labor in the first stage which 
calls for the application of the forceps varies to a 
much greater extent than in the second stage. The 
first stage is extremely variable in length even in the 
same individual in different labors, and its pains can 
almost always be endured for a much longer time 
than those of the second stage. Hence, a duration 
demanding assistance must be determined in each 
instance by the condition of the mother. All other 
approved means are to be tried before resorting to the 
forceps, but if her condition is at all unfavorable, 
we should have no concern as to the mere number of 
hours which have elapsed, but proceed at once to 
render assistance. Another application of the for- 
ceps during the first stage is for the complication of 
placenta previa. It is sometimes recommended to 
introduce the forceps after a sufficient amount of di- 
latation has been secured, merely to cause the head 
to press against the cervix and so arrest the hemor- 
rhage. This, to be entirely successful, would require 
the head to be constantly pressed against the cervix. 
It is much better to first detach the placenta from 



164: HOW TO USE THE FORCEPS. 

the cervical zone, after the manner of Barnes, after 
which the hemorrhage usually ceases. If previous 
loss of blood and other conditions make it necessary 
to deliver forthwith, the forceps may then be used, 
and this application of the instrument is one of the 
most useful of the modern purposes to which it has 
been devoted. For without it we must resort to the 
more formidable operation of version, or await the 
slow, often fatally slow, spontaneous dilatation of 
the cervix. 

III. Certain accidents of labor require a more or 
less prompt termination of the labor. In prolapse 
of the funis, when it cannot be permanently replaced, 
the forceps may be used in the interests of the child. 
The forceps blade may be of great utility in itself, in 
pushing the funis up and out of the way, after 
which we may make as much or as little traction as 
is called for, and either promote the delivery with 
them or allow it to go on without further interfer- 
ence. This will not interfere with the trial of the 
genu-pectoral posture in replacement. This position 
has been found useful as a preliminary measure in 
the application of the forceps in these cases, and is 
also recommended by Mossmann (Am. Journ. Obst., 
Jan. 1879), in certain cases of spinal and pelvic 
deformity. There is such an entire reversal of direc- 
tion in this position that the operator must know 
well what he is undertaking ; otherwise it is calcu- 
lated to be of service. 



WHEN TO USE THE FORCEPS. 165 

Convulsions. — The typical puerperal convulsion 
comes on usually when the head has reached the in- 
ferior strait and the bearing down efforts of the 
mother giye rise to cerebral congestion. The indica- 
tion is then plain to apply the forceps at once and 
deliver as speedily as possible, administering ether 
in the meantime, if it is at hand. We thus eliminate 
one of the causative factors of the eclampsia and gen- 
erally put an end to the seizures. In the cases 
which occur during the first stage, rapid delivery is 
not so necessary. We have ample time to obtain the 
influence of chloral by the mouth or rectum, bleed, 
or otherwise control the convulsions according to our 
lights. Dilatation is usually rapid, and when com- 
plete we can apply the forceps with less risk. In 
cases of hemorrhage before delivery the forceps also 
afford us the means of promptly terminating the labor. 

IV. When rupture of the uterus has taken place, 
the prevailing practice is to deliverer vias natu- 
rales, either by the forceps or version if possible. 
The propriety of this begins to be questioned. 
First, we will probably enlarge the rent already 
made. Second,, we leave the rent to close spon- 
taneously, which seldom happens, Thirdly, we do 
not take away what is quite as important should be 
removed as the child, the blood and fluids which es- 
cape at the time of rupture. The elaborate statistics 
of Dr. Trask show a better percentage for gastrotomy 
than for ordinary delivery and with the improved 



166 HOW TO USE THE FORCEPS. 

methods of operating now in vogue there is no rea- 
son why a much larger percentage should not recover 
if we should at once proceed to open the abdomen 
after the accident. The child can be removed, the 
rent united by suture, the abdominal cavity thor- 
oughly cleansed from extraneous fluids, and the 
woman will be no worse off than after the Cesarean 
section instead of almost uniformly perishing, as 
when the abdomen is left unopened. It is true that 
gastrbtomy may be performed after delivery per vias 
naturales, but the latter is an unnecessary step, and 
the former would be frequently refused by the 
woman or her family if she had been already deliv- 
ered. Prevention is better than cure, and the for- 
ceps will be found much more useful as a preventive 
of rupture. When the uterine contractions are very 
forcible without having any appreciable effect upon 
the head, we may justly fear the occurrence of rup- 
ture of the uterus. The exact amount of contrac- 
tion which justifies interference may be left to the 
judgment of the practitioner at the time. The for- 
ceps may also be used for purposes foreign to their 
original design. They may be inserted into the in- 
cision made in the Cesarean section or gastro-ely- 
trotomy, in order to grasp the head. They may be 
used to deliver detached fibroid tumors from the va- 
gina, or to extract foreign bodies, such as globe pes- 
saries. But for such purposes the mechanical tact of 
the operator in each case is a sufficient guide. 



WHEN TO USE THE FORCEPS. 167 

A few words may be added as to the possibilities 
for harm possessed by the forceps. So far as the 
mother is concerned we may reiterate the statement 
that there is nothing in the right use of the instru- 
ment which can by any possibility injure her. The 
animadversions of the earlier writers were due, in 
part, to their wrongly attributing to the instrument 
what is the result of delay in labor, and in part to 
the unavoidable injuries caused by an instrument 
without a pelvic curve, to say nothing of the heavy, 
thick, leather-coverad blades which formerly belong- 
ed to the forceps. But with the modern instrument 
we can do harm only by violence in introduction, a 
wrong direction in traction, or by too great haste in 
completing the delivery. The anterior lip of the 
cervix has been ground off, the pubic bones have 
been fractured, the vagina lacerated, by such im- 
proper uses ; but none of these things will happen 
when the forceps are used as herein directed and as 
common-sense would dictate. And in the normal or 
but slightly deformed pelvis, it is equally true that 
the forceps need do no harm to the child, if applied 
to the sides of the head and used intermittently and 
judiciously. It must be admitted that even those 
who are skilled in their use are occasionally mistaken 
in the diagnosis of the position of the head, and 
hence apply them over the brow and occiput, but 
this should not be laid to the charge of the forceps. 
So, also, when the head is at the inferior strait, but 



16S HOW TO USE THE FORCEPS. 

has not completed rotation, the exact state of affairs 
may be overlooked and the forceps applied obliquely 
upon the head. In occipito-posterior positions, es- 
pecially when flexion has not taken place, the ends of 
the forceps may unavoidably compress important 
structures, and in deformed pel res indentations of 
the cranium may be caused by the jutting promontory. 
We may have, then, as the result of the forceps, 
bruising or laceration of the child's scalp, facial pa- 
ralysis, asphyxia from compression of the medulla, 
indentations of the cranium. All of these are avoid- 
able by applying the forceps to the sides of the head, 
except those due to compression of nerve trunks in 
occipito-posterior positions. Against these we have 
no safeguard, except the early securing of flexion so 
as to bring the line of the blades parallel to the oc- 
cipito-mental diameter, and. failing this, the utmost 
care in compression and traction, which as already 
pointed out, is proper for other reasons as well. Di- 
rect indentations of the cranium are rarely if ever 
caused by the direct pressure of the forceps, but the 
amount of traction necessary to bring a head past a 
jutting promontory may cause the latter to indent 
the head, as happens also in head-last labors. The 
etiology of identations in general is well worked up 
by Dr. J. Trash, to whose paper* the reader is re- 
ferred for a more extensive discussion. 

* "American Journal of Obstetrics," July. 1879. 



PART III. 



APPLICATION 



AND 



CASES. 



CRITICAL REMARKS. 

The shape and directions of the pelvic tube as de- 
scribed in the pages devoted to the " Anatomy of the 
Pelvis " call for more than a passing mention. The first 
point of importance to be mentioned is outlined on 
page 21, and more clearly demonstrated in the following 
pages. The pelvic canal is a double one, being in reality 
two canals whose axes gradually approach each other 
from above downward until they meet and unite 
into one as the axis of the outlet. Fig. 7 shows 
the shape and direction of these two canals from the 
inlet to the pelvic tube. A is the sacrum, and the dotted 
lines A B and A C complete the outline of the beginning 
of the two elliptical tubes of which the pelvic canal is 
composed. A part of the pelvic inlet, the spherical tri- 
angle ABC, is common to each of these ellipses. These 
elliptical outlines form the beginning of the right and 
left pelvic tubes, the axes of which approach the median 
line as they descend in the pelvis. They also participate 
in the general curvature forward which is shown by a 
median section to exist in the pelvic canal. Their junc- 
tion at the outlet forms the axis of that part of the canal. 

It is needless to recapitulate the proofs of the exist- 
ence of this duality in the pelvic tube. The inspection 
of any normal pelvis will demonstrate its presence at 



172 HOW TO USE THE FORCEPS. 

the inlet, and careful observation of any normal labor 
demonstrates it by the movements of the fetal parts, the 
head being engaged in either one or the other of these 
canals. This gives rise to the different presentations, 
which might with propriety be divided into two, the 
right and the left. The entrance of the fetal head into 
the left canal would be the left presentation, and its en- 
trance into the right canal, the right presentation. 
These of course have a further subdivision, according 
as the occiput is backward toward the sacro-iliac syn- 
chondrosa or forward toward the acetabulum, as "pos- 
rior" and "anterior" in each canal. This gives the 
four presentations usually described. 

Knowledge of the existence of these two canals and 
of their relations to each other and to the presenting 
part is of the utmost importance to a definite under- 
standing of the mechanism of labor. A definite com- 
prehension of the mechanism of labor is an absolutely 
necessary prerequisite to the correct use of the forceps. 
Consequently a correct and intelligent use of the 
obstetric forceps is impossible without a thoroughly 
accurate knowledge of the correct anatomical formation 
of the pelvis and the directions of its canals. 

The fact that the fundus uteri is not in the median 
line at any time during the first, and rarely during the 
second, stage of labor is another evidence of the obliquity 
of the line in which the uterine forces act. In the early 
stages of labor the uterus can always be felt at one side 
of the abdomen of the mother, and the oblique direction 



CKITICAL EEMARKS. 173 

of its axis can clearly be demonstrated by palpation. 
In many cases it is possible to determine in which canal 
the presenting part has engaged from an examination 
of the abdomen alone without examination per vagi- 
nam. It is never advisable to rely on this kind of super- 
ficial examination, but much assistance can be received 
from carefully outlining the position of the uterine body 
in determining an obscure presentation when the head 
is yet high and difficult to reach. 

~No one should attempt to apply an obstetric forceps 
until the presentation has clearly and definitely been 
determined. These instruments have been made after 
much effort and care being devoted to adapting their 
curves to fit the fetal head, as well as to conform to the 
curves of the maternal parts. Consequently they can- 
not be properly applied to the head unless its exact 
position is known to the operator. That this care is not 
always taken is shown by the marks the forceps blades 
frequently make on the fetus. As a rule these marks 
disappear in a few days, but their position tells the story 
of faulty or rather hap-hazard application. The fetal 
mortality would be much less from the use of forceps if 
this ignorant or careless manner of using them was 
eliminated. 

The blades of the forceps are intended to fit over the 
parietal eminences of the head of the child. If there 
are fenestrae in the blades (as there should be) the most 
prominent parts of these eminences will project through 
to such an extent that the bi-parietal diameter of the 



174 HOW TO USE THE FORCEPS. 

head is not increased by the blades of the instruments 
when properly applied. The part of the head to 
which the blades are applied is of importance to the 
integrity of the intro-cranial parts of the fetus. The 
prominences on either side of the head come in contact 
with the maternal parts in a normal delivery. They 
receive the greatest amount of the pressure and are 
adapted to receive it without injury to the contents of 
the cranium. If pressure is required to make the head 
smaller, the overlapping at the inter-parietal suture will 
permit considerable shortening of the bi-parietal dia- 
meter. This can be aided by pressure with the forceps 
blades if the instruments are in their proper position 
around the fetal head. This pressure can be exereised 
during each pain and removed by separating the handles 
during the intervals between the pains. In this, as in 
all aids to natural processes, it is safest to imitate the 
natural method. The soft parts within the skull are 
rarely injured by pressure that is not exerted during too 
great a period of time. 

When the forceps blades are applied to any other 
part of the head pressure does harm in at least two 
ways. It is applied to parts of the head that cannot be 
compressed without injury to the soft parts within, and 
pressure to lessen the other diameters has a tendency to 
increase the bi-parietal diameter. 

A number of cases have come under my observation 
in which I am sure the death of the fetus was directly 
due to pressure of forceps blades on a part not adapted 



CRITICAL REMARKS. 175 

to receive it : or to speak more exactly, to parts which 
the instrument was not shaped to fit. This has most 
frequently occurred when the blades embraced the occi- 
pitofrontal or oblique diameters. Cases will be given 
in detail in the following pages to illustrate this fact. 

The second result may not be so evident as the first, 
yet it can be as clearly demonstrated. In normal labor 
the occipito-frontal diameter is not the one that needs 
shortening. In a normal case, this is accomplished by 
flexion of the head on the trunk, thus substituting the 
shorter diameters for the occipito-frontal. If the flexion 
is only partial the bi-parietal diameter and the shortest 
antero-posterior diameter are each in the plane of demi- 
flexion. This shortest antero-posterior diameter is the 
cervico-frontal and is considerably shorter than the 
occipito-frontal. If complete flexion is required to 
permit the head to pass the diameter of its position in 
the pelvis, the cervico-bregmatic is yet shorter than that 
of partial flexion. This mechanism of normal labor 
makes shortening of the antero-posterior diameters of 
the head by pressure unnecessary. The exercise of 
pressure in this direction must cause bulging in the 
other diameters, and particularly in those at right 
angles to the line of pressure, i. e., the bi-parietal. This 
is precisely the diameter that requires shortening if any 
from pressure is needed. 

Again, if the forceps are applied so the blades press 
against the ends of the bi-parietal diameter, and flexion 
is not produced by the unequal resistance the head 



176 HOW TO USE THE FORCEPS. 

offers to the force from above, it is possible to cause 
it by moving the handles towards the face of the 
child. Again the necessity of knowing the exact 
presentation is evident, or we might retard, instead of 
assisting, flexion by mistaking an anterior for a posterior 
position, or vice versa. The manner in which flexion 
occurs in a normal labor, because of the force from 
above being communicated to the head nearer its poste- 
rior end, needs no further elaboration here. 

THE PERINEAL BODY. 

It is customary to think of but two forces in the 
mechanism of labor. They are the contractions of the 
uterine muscle and the assistance it receives from the 
contractions of the abdominal muscles and the dia- 
phragm. Another element that is sometimes considered 
in this connection is the action of the inclined planes 
of the bony pelvis which gives to the head its rotary 
motion. This is not properly a force at all, but simply 
a resistance causing a change in the direction of the 
movements caused by the first mentioned forces. There 
is no active force exerted by the walls of the bony pelvis 
per se. But there is another force, active and important 
in its bearing upon labor, that rarely receives any atten- 
tion when considering this subject. This is the action 
of the perineal body. 

The perineum is the name given to that portion of 
skin between the rectal and vulvar outlets, and extend- 
ing as far as the ischiatic protuberance on either side of 



THE PEEIKEAL BODY. 177 

the median line. The more important perineal body is 
made up largely of fibrous tissue and muscles attached 
thereto. This structure is of triangular shape, the lines 
of the triangle being the perineum, the anterior wall of 
the rectum, and the posterior wall of the vagina. To 
one familiar with the anatomy of these parts it is appar- 
ent that the last named side of the triangle is the long- 
est, and the side bounded by the perineum and seen 
externally is the shortest. The angle formed by the 
lines that meet at the anus is an obtuse angle. None 
of these sides are absolutely straight lines, and the vagi- 
nal boundary is a decided curve. This curvature is in- 
creased when the vagina is distended. The concavity 
of the curve faces anteriorly and upward. 

The muscles attached to the fibrous perineal body 
should be considered as a part of it when describing it. 
They are attached to the coccyx behind, the pubic arch 
in front, and the ischiatic rami and protuberances at 
the sides. These muscles are placed in such a way that 
any shortening in their fibers will cause the muscles to 
draw upon the perineal body. When all these muscles 
act at once, this body is caused to move upward and 
slightly forward. The perineal body is really the point 
of attachment, in or near the center of a blanket which 
forms the lowest layer of the pelvic supports. The four 
corners of this muscular blanket are attached, as above 
stated, to the coccyx, the pubic arch, and the ischii. 
The vagina and anus are simply linear openings in this 
support. 



178 HOW TO USE THE FORCEPS. 

In labor the head progresses downward and back- 
ward until it reaches the lower limit of the bony pelvis. 
By this time it has usually escaped from the cervix and 
this stage of labor is completed. The presenting part 
then comes against the posterior wall of the vagina. 
This is the longest side of the perineal triangle. As 
the forces from above push the head against this resist- 
ance, the muscles supporting the perineal body also con- 
tract, raising that part. This has the effect of deflecting 
the direction of motion of the fetal part, causing it to 
move in a line forward and slightly downward. This 
line of motion is in the direction of neither of the 
forces acting upon the presenting part, but is a re- 
sultant of their combined action. 

The change in the direction of the motion of the 
child in the parturient canal above outlined, cannot be 
ignored in the use of forceps, without disastrous results, 
Many torn perinei result from failure to remember this 
mechanism, in labors where no artificial aid is required. 

When the head comes against the posterior wall of 
the vagina, and the perineal body, drawn by its muscular 
attachments, becomes a factor in the mechanism pro- 
ducing the expulsion of the fetus, the action called 
"extension " begins. If the head has passed under the 
symphysis pubis, this movement can be aided by raising 
the handles of the forceps. This must be done while 
the fetus is descending, and the utmost regularity is 
needed to make it free from danger to the perineum. 
When the head has been expelled from the vagina it 



THE USE OF THE FORCEPS. 179 

must be held up either by the hand or the forceps, and 
not be permitted to fall backward. A lacerated peri- 
neum is sure to follow neglect to observe this precau- 
tion. The maternal parts must be protected in the 
same way during the birth of the lower shoulder. It is 
well to carry the child upward toward the mother's abdo- 
men, keeping all the weight possible off of the perineum. 
Hurry to get the child out should be avoided, and it is 
better not to introduce a finger into the axilla, as is so 
commonly done. The life of the child is rarely endan- 
gered by a little delay in this stage of the labor, and the 
integrity of the maternal parts is greatly conserved by 
avoiding haste at this time. 

The perineum may also be ruptured by efforts to re- 
move the placenta. This is particularly the case where 
the hand or any portion of it is introduced into the va- 
gina for this purpose. 

THE USE OF THE FORCEPS. 

The following extracts from a report of a case pub- 
lished in a recent medical journal will illustrate the 
need of a better knowledge of when and how to use the 
obstetric forceps. "It took fourteen hours before any 
degree of satisfactory position was obtained. Tlie 
straggle then commenced in earnest" "I applied 
brandy over the epigastrium, cold water over the fun- 
dus, and a faradic current of electricity on the sides of 
it." Later, after "the facial muscles began to twitch, 
showing symptoms of convulsions/' only controlled by 



180 HOW TO USE THE FORCEPS. 

"a powerful antispasmodic," the second stage of labor 
began. The history goes on, " When at last the occiput 
presented at the vulva, it met with such a firm opposition 
in the perineum that it took five hours to dilate suffi- 
ciently for the passage of the head. " " The whole labor 
consumed forty-two hours. Mother and child are safe 
and doing exceedingly well, the perineum is intact, and 
my record of never having resorted to forceps, nor lost 
a woman in confinement, remains still unbroken during 
the past thirty years." 

This history shows several things. The writer of it 
feels that a labor of forty-two hours, allowing the patient 
to become exhausted to the point of impending convul- 
sions, is preferable to the use of forceps and a possible 
lacerated perineum. I yield to no one in my apprecia- 
tion of the importance of the perineum. But suppose 
it is shown that the liability to rupture that very im- 
portant body is not increased by the use of the forceps 
when intelligently handled ? Would the doctor then be 
willing to break her record in regard to their use, rather 
than keep a woman on the rack for forty- two hours ? 

To me this history is as terrible as the stories of hor- 
rible sufferings from torture, with which ancient history 
is filled. And I hope the time is not* far distant when 
such treatment, or rather want of it, will be ancient 
history; when a "record" like the above will be some- 
thing to regret (if a stronger word is not called for), 
instead of cause for pride and self-congratulation. 

I have a '• record" too, though I have not practiced 



THE USE OF THE FOKCEPS. 181 

thirty years. I have never lost a woman in the puer- 
peral period or following abortion, and the cases have 
been numerous and scattered over all classes of society. 
This record can be equaled by many older men than I, 
and I consider it a matter more of accidental circum- 
stances than a result of special skill. It certainly is not 
due to not using the forceps. I never go to a case of 
labor without these valuable instruments, and I never 
hesitate to use them when indicated. 

In regard to rupturing the perineum, the worst case 
I ever saw occurred when no instrument had been used, 
nor was there any indication for its use. I believe, the 
proper use of the forceps would save the perineum in 
many cases, where it would be torn if delivery was per- 
mitted to terminate without them. I also believe, that 
many children would be born alive, and free from injury 
to the intra-cranial organs, if the forceps were judici- 
ously used, that are now dead-born, or if they survive 
surfer from cerebral lesions, which either eventually 
destroy their lives or permanently impair their useful- 
ness. 

It is self-evident that harm can be done with the ob- 
stetric forceps, and injury is frequently the result of 
their use. But 'can one who points with pride to a 
"record" of never having used an instrument be con- 
sidered a competent critic ? 

Equally reprehensible is the physician who is always 
in a hurry to get the case finished. He uses the forceps 
to save his own time, applying them as soon as the cer- 



182 HOW TO USE THE FORCEPS. 

vix is dilated to a degree sufficient to admit of their 
easy introduction. Physicians of this class are largely 
responsible for the fears of injury from the instruments 
so frequently expressed. The torn perinei are many of 
them caused by undue haste. The physician who is in 
a hurry is not apt to be careful in his technique. Time 
is frequently required to make out the presentation, and 
more time and care is needed to adjust the forceps blades 
properly to the head. Again, further time is consumed 
in directing the forces in the direction of the least resist- 
ance, rotation and flexion have to be assisted, and time, 
to know the proper stage of each of these movements, 
is again called for. All these things must receive 
patient consideration. But patience is just the article 
the "hurry" obstetrician lacks most. His "time is 
valuable." What cares he for a "little tear." He can 
easily sew it up again, either by immediate or later 
operation. Consequently he applies the forceps without 
knowing where. If he can get the blades around the 
head and lock them he is satisfied. Then comes the 
"assistance." He is the man who pulls long and hard, 
often drawing the head directly against the symphysis 
pubes, bruising the anterior lip of the cervix and adjacent 
soft parts, it may be, injuring the urethra and bladder. 
The cervix sloughs as a result of these bruises and, if 
torn, does not unite as it would if simply torn without 
bruising. When the head is brought to the perineum, 
that part is ruthlessly torn asunder by drawing too 
much backward. The soft sides of the parturient canal 



THE USE OF THE FORCEPS. 183 

are bruised and injured by the side to side motion given 
the head, in frantic efforts to bring it through a tube, 
that contains important organs, capable of injury. Fin- 
ally the head is born and dropped, while the shoulders 
are drawn down and out, a portion of the hand being 
frequently introduced into the vagina, in order to get a 
finger in the axilla, by which to make traction. If the 
perineum has not been already torn, this maneuver can 
easily break it through, and a small tear can easily be 
made a serious one by it. Yet women and children 
survive this treatment. We read cases where precisely 
these actions are described in published accounts. The 
sequence is seen in the large number of gynecologists 
who are kept busy treating the injuries resulting from 
such unwise use of the forceps. 

The results to the. fetus can be found in the number 
of children born dead, or who die from resulting injury 
to the brain during the first weeks after birth. A few 
receive injuries that make them sufferers from epilepsy 
or other brain disorder, yet are not sufficient to kill. 

The preceding pages have given a description of the 
two extremes in regard to the use of instruments to aid 
delivery. The first is not so common as the second. 
The number who refuse absolutely to give assistance in 
such cases is small, when compared to the number who 
use them. Yet a very considerable number of medical 
men are what they call "conservative" in this matter, 
and put off the use of forceps, hoping that "nature" 
will eventually complete the delivery without their aid. 



184 HOW TO USE THE POKCEPS. 

Is not much of this " conservatism" due to uncertainty 
as to when the time to use them has arrived ? The in- 
dications for the use of the obstetric forceps should be 
as clear as the indications for opening an abscess. If 
the manner of using them was as thoroughly understood 
as the manner of using a lancet, perhaps less uncertainty 
as to when to use them would exist. 

If the directions given in the preceding pages are 
carefully studied and mastered, no doubts will exist in 
the mind of the physician thus informed. The result 
will be many hours of pain saved for suffering women. 
The saving of strength consumed in prolonged labor is 
no inconsiderable item, and the future condition of the 
woman is more favorable for continued health when 
this call upon her vitality is reduced to a minimum. 
Let a man subject himself to forty-two hours of almost 
continuous muscular effort, without pause for sleep or 
nourishment, and see how long he will require to regain 
his former strength and well-feeling. Many weeks are 
frequently required to restore the patient to her former 
health, after these prolonged labors. Could she be worse 
with a little tear in her perineum ? Prolonged labor is 
no guarantee that she will be saved by it from that 
catastrophe, even though no instrument is used to aid 
her. The forceps properly used should not tear the 
perineum. 



PREPARATION FOR THEIR USE. 185 

PREPARATION" FOR THE USE OF THE FORCEPS. 

When it has been decided that the uterine muscle 
needs assistance to enable it to expel the fetus within a 
period of safety to the mother and child, several things 
should be done preparatory to the introduction of the 
instruments. Some of these will frequently have been 
done already as part of the routine preparation for de- 
livery. But in order to be systematic all will be men- 
tioned. They can be divided into three groups. Pre- 
paration of the surgeon, preparation of the instruments, 
and preparation of the patient. 

Preparation of the Surgeon comes first, and requires 
the most punctilious attention to routine. In the first 
place, as Prof. McLane tells his classes, the custom of 
having a special obstetric suit cannot be too much con- 
demned. The clothing should be clean, and free from 
germs of any kind. Every obstetrician should know 
the danger of attending cases of erysipelas, or other con- 
tagious or septic diseases, at the same time he attends 
confinements. Puerperal septicaemia is sure to result. 
Stains from autopsies or operations are also sources 
of danger, and should not be carried into the lying-in 
room. 

To protect the clothing it is well to improvise some 
covering. A large apron can usually be found that is 
clean, or a large towel can be pinned around the waist. 
The hands and arms must be cleansed as thoroughly as 
for any other surgical procedure. This should include 



186 HOW TO USE THE FORCEPS. 

thorough scrubbing with soap and warm water, or better, 
some tincture of green soap can be poured over the 
hands, and the arms thoroughly washed with warm 
water. The finger nails must be cleansed and scrubbed. 
After the hands are dried it is advisable to pour ether 
over them and the arms, and bathe them well in this 
fluid. This ether bath should be taken just before 
approaching the woman to introduce the instruments, 
and after everything else is prepared. 

Preparation of the Instruments includes scrubbing 
in the green soap solution, to be followed by immersion 
in boiled water at a temperature of 80° C. They 
should then be laid on a clean towel within easy reach, 
and just before using should receive the same ether 
bath as is given the hands. 

Preparation of the Patient, while given last, should 
be first attended to. To begin with she should have an 
enema to cleanse the rectum. The best fluid for this 
purpose is warm water containing tincture of green soap 
and some glycerine. The soap must not be so strong as 
to cause discomfort by the smarting produced. The va- 
gina should then be douched out freely with warm water; 
the last quart or two may have bichloride of mercury 
(1 to 10,000) or acid carbolic (1 to 40). I prefer borax 
or boric acid, two or three drachms to a quart, to the 
stronger, and consequently more dangerous, germicides. 
After the vagina and rectum are thus washed out, the 
external genitalia must receive attention. The vulva, 
mons veneris, and the adjacent skin on thighs, abdo- 



PREPARATION FOR THEIR USE. 187 

men, buttocks, and perineum should all be subjected to 
a generous scrubbing with, warm water containing the 
tincture of green soap, and again washed in clean warm 
water to remove the soap, after which ether should be 
poured over and rubbed through all these parts. It is 
especially desirable to see that the parts covered with 
hair are cleansed with thoroughness, and the hair itself 
made scrupulously clean. If any difficulty is found in 
securing this result the hair must be removed, and the 
parts under it then cleansed. 

It is unnecessary to add that the bed and the cloth- 
ing of the patient, and everything about her, requires 
the same scrupulous care that it is clean, and it should 
be kept so by removing soiled pieces at once. 

The position of physician and patient, and man- 
ner of introducing the blades, have been described with 
sufficient minuteness elsewhere, and need no further 
mention here. But I must again call attention to the 
futility of all attempts to successfully use the obstetric 
forceps, unless the presentation is exactly known before 
the blades are allowed to pass the vulva. They must be 
applied at the sides of the fetal head, over the parietal 
eminences. I have seen children delivered by forceps, 
with the mark of one blade over the forehead or face, 
the other blade having been over the occipital protube- 
rance, or caught over the mastoid process. These babies 
are generally dead born, I think as a direct result 
of the pressure. The pressure of the instruments on 
the long axis of the head also tends to increase the 



188 HOW TO USE THE FOKCEPS. 

biparietal diameter, and act as an impediment to deliv- 
ery rather than as a help. These are the cases in which 
excessive force is required, and usually result in a torn 
cervix and perineum, as a consequence of the improperly 
applied instruments. The surgeon who produces these 
results because of incorrectly applied instruments is an 
incompetent operator, and should get some one to apply 
forceps for him when needed and when the exact pre- 
sentation is accurately denned. The work of such men 
causes conscientious physicians to go to the other ex- 
treme, as in the case of the doctress already quoted, who 
boasts she has never used forceps during over thirty 
years of obstetric practice. 

SYMPHYSEOTOMY. 

The consideration of " How to Use the Forceps " will 
not be complete without mention of symphyseotomy. 
This operation is done when the pelvic canal is too 
small, from deformity or other cause, to allow the fetal 
head to pass. In itself the operation is a simple one. 
The symphysis pubis is opened, and the rami forming 
the pubic arch are permitted to separate. This widens 
the pelvic canal, and will permit a fetus to be extracted 
with the forceps, much larger than could otherwise 
come through the bony pelvis without destroying the 
life of the child. The operation has been occasionally 
done during a period covering a number of years, but 
the past year it has become more in vogue than ever 
before. 



SYMPHYSEOTOMY. 189 

The indications for the use of symphyseotomy are 
not frequently met, and it will not be resorted to so fre- 
quently after it has ceased to be new. The field for the 
operation is limited. The amount of increase in the 
interpelvic measurements, safely made by it, is limited 
to about one inch in the transverse diameters. This 
will also lengthen the antero-posterior diameters of the 
right and left canals, as described in Section I, but to a 
smaller degree. 

The chief risks attending the operation are sepsis 
and deformity, resulting from the failure of the bones to 
reunite after the delivery. Both are liable to occur. 
Sepsis is frequent because of the presence of septic 
material in the immediate vicinity of the field of opera- 
tion. It can only be avoided by the care of physician 
and nurses during and after the operation. Death in 
cases reported is usually from this cause. 

Failure of the bones to reunite is not common, and 
should not occur in a properly selected case. If the 
bones are diseased the operation should not be attempted. 
Absence of union of the pubic arch will destroy the sup- 
port of the trunk by the femurs, and leave the woman 
unable to walk or stand. 

The operation itself is easy to perform. After the 
parts have been cleansed and shaved, the ridge indicat- 
ing the line of union of the arms of the pubic arch is 
found, and cut down upon by a vertical incision. A 
blunt-ended knife is then inserted beneath the bones, 
and they are separated by an incision from within out- 
ward. It is desirable to cut through the bursa. 



190 HOW TO USE THE FOKCEPS. 

The child is then delivered with the forceps accord- 
ing to the directions already given. If the separation is 
liable to be too great, the sides of the pelvis must be sup- 
ported by the hands of an assistant. A separation of 
4.5 to 5.5 centimeters is reported, but this patient died 
in the ninth day of septicaemia. One and a half inches 
is about the limit of separation allowable with safety. 

After delivery the bones are brought in apposition, 
and the soft parts united by sutures. The pelvis must 
be held together firmly by a bandage that will keep the 
two sides of the pelvis immobile until the bones can unite. 

The wound should be cleaned, and kept so. The 
occurrence of septicaemia is evidence of uncleanliness 
in some respect, and can usually be avoided. If the 
separation is enough to cause laceration of the soft parts, 
pockets may form, in which pus or blood will collect, 
and sepsis result. 

It will be seen from what has been said, that an exact 
knowledge of the size of the head and pelvis is neces- 
sary, in a given case, to decide if it is a suitable one for 
this operation. Any one not capable of making the 
measurements to give this knowledge should not 
attempt it. Where the pelvis is small many prefer the 
induction of premature labor as soon as the child is 
viable, and the use of forceps to secure a speedy deliv- 
ery. When the case has advanced beyond this point 
before it is seen, symphyseotomy may be done, if an 
increase of an inch in the lateral diameter of the pelvis 
will permit the head to pass. If the pelvic canal is 



ILLUSTRATED CASES. 191 

below this limit of size, the child should be removed 
through an opening in the abdominal wall. 

ILLUSTRATED CASES. 

The following cases are taken from my case book. 
They are all forcep cases in which no tear occurred in 
the perineum. They represent cases \arying from pri- 
miparse to multiparas in their tenth delivery. In all of 
the cases the patient has been under observation a suf- 
ficient time, since the operation, for the development 
of symptoms due to the use of forceps, if any were to 
follow. Yet none are found. 

Case I. — Mrs. J. L , aged 29 years. Third child. 

The second time attended by me in confinement. The 
last child, now over two years old, was born without 
instruments. The mother has been subject to fits 
resembling epilepsy, which are absent during gestation 
but usually occur with the menstrual periods. There 
was no albuminuria. She was very nervous and weak, 
and feared she would have one of her convulsive attacks 
if the labor was not soon terminated. She soon worked 
herself into a state of needless fright, and the pains 
all died away. There was nothing to do but remove 
the child as soon as possible. This was urgent, to save 
the child as well as to relieve the mother from a condi- 
tion growing hourly more dangerous to both. 

The head was well down in the bony pelvis, and the 
presentation was easily made out to be a left occipito- 
anterior ; that is, with the head in the right canal, and 



192 HOW TO USE THE FORCEPS. 

the back of the child towards the mother's abdomen. 
The hour was late, the case urgent, and I was entirely 
alone. To get an assistant meant delay, and possibly 
convulsions. After explaining the situation to her hus- 
band, I decided to use the forceps alone, and conse- 
quently without an anaesthetic. As I had just finished 
reading Prof. Landis' book, I concluded to follow his 
directions in every particular. 

Accordingly the blades were introduced with care, 
and the fenestra in each made to embrace the parietal 
eminence on that side of the fetal head. The instru- 
ments were introduced without causing the least com- 
plaint of inconvenience from the woman. There was 
no difficulty in getting them properly placed and locked. 
When this was done the uterine muscle showed some 
inclination to contract. This was probably due to the 
stimulating effects of the presence of a foreign body 
within the uterus, and was in a large measure aided by 
the restored courage of the patient. The idea that she 
is receiving help is an important thing with a woman in 
the mental condition in which she was. 

The contractions were quite faint, and would have 
accomplished nothing of themselves. The traction 
made was all done with one hand, and not more than 
two pounds of force was employed at any time. The 
thumb and fingers of the other hand were introduced 
within the vagina to the cervix, and there held against 
the blades, as directed on page 127, and shown in Fig. 
24: on that page. The results were gratifying, and sub- 



ILLUSTRATED CASES. 193 

stantiated all that is there claimed for this method. 
The head passed under the symphysis pubis with ease. 
The precautions of resting between pains with the for- 
ceps unlocked, to release the head from all pressure, 
was carefully observed. As the perineum began to act 
the handles were made to sweep forward and upward, 
thus holding the head from falling backward, as it is 
inclined to. This dropping of the head as soon as it is 
expelled from the vagina, causes more ruptures of peri- 
nei than the use of forceps. In this case the instru- 
ments retained the fetal head between the blades, until 
the handles reached the abdomen of the mother. The 
birth of the shoulders was not hurried, and another 
danger to the perineum was reduced to the smallest 
item possible. 

The fetus was delivered in about forty minutes from 
the time the introduction of the forceps was begun. 
There was no mark to be found anywhere upon the fetal 
head, and the perineum was not even nicked. At no 
time was the traction employed so great as to require 
either the patient or the surgeon to be braced either 
against the bed or by a third person. 

This woman has been seen and examined a number 
of times, since the delivery above described, and she is 
as well, in all respects, as she was before the labor 
began. The child is also alive and in perfect health. 
No marks from the f orcep blades could be found on the 
head at birth. 

Case II. — Mrs. S. M. , age 21 years. Primipara. 



194 HOW TO USE THE FOECEPS. * 

Labor lasted about ten hours, when she was completely 
exhausted. The pains became further apart, and finally 
ceased entirely. The membranes had ruptured the day 
before. The woman began to feel very faint, and could 
retain no nourishment. She had vomited. Forceps 
were applied and used as in Case I, no assistant being 
available, and consequently no anaesthetic being used. 
The delivery was accomplished in forty-five minutes. 
The perineum was uninjured, and mother and child are 
now doing well. The woman was examined in the third 
month after delivery, as is my custom, and has only a 
slight indentation in one side of the cervix as a sequel 
of the birth of her child. 

Case III. — Mrs. L. , age 21 years. Primipara. 

Labor really began the day before I saw her, with pains 
every half hour, or thereabout. When first seen the 
contractions were strong, and from eight to twelve min- 
utes apart. The presentation was the usual First posi- 
tion. The membranes ruptured about two hours later. 
The labor progressed until the cervix would admit four 
fingers, and the head was tightly wedged in the bones of 
the pelvis. An hour and a half was spent in fruitless 
efforts to make further progress. The contractions then 
became progressively weaker, and the patient lost cour- 
age with their departure. She was advised of the possi- 
ble aid she might receive, and was anxious to have the 
proffered assistance at once. Accordingly the forceps 
were applied, and the delivery completed in less than an 
hour. There was no injury to the perineum, and the 



ILLUSTKATED CASES. 195 

mother is in all respects well. She has since been seen 
and examined, and is now again pregnant about six 
months. 

The child had a large liver when born, and never 
breathed as it should. It died in about thirty hours. 
There was no evidence of injury to its head from the 
forceps, nor symptom of injury from their use. It was 
slightly jaundiced when born, showing interference with 
the hepatic function. This was also indicated by the 
enormous distention of the abdomen due to enlargement 
of the liver. 

Case IV. — Mrs. M. A. , age 21 years. Primipara. 

She had now of water from the vagina in small amounts 
for about forty hours, before pains became at all severe. 
She then waited six hours longer, before sending for me. 
When seen the membranes were ruptured, and the cer- 
vix was dilated to admit two fingers. Presentation nor- 
mal. Pains every five minutes, and within the next 
half hour became as close as every two minutes. When 
the dilatation had reached a size large enough to admit 
four fingers all advance ceased, and two hours were spent 
in patient efforts to make further progress. Then the 
intensity and frequency of the uterine contractions began 
to be less, until she only had a slight "pain" every 
twenty minutes. Forceps were suggested and used, and 
the child was born within a half hour. Not more than 
six pounds traction was used at any time. The perineum 
was not torn by the head in the slightest degree, but the 
woman became somewhat excited and contracted the 



196 HOW TO USE THE FOECEPS. 

abdominal muscles forcibly, at the same time the uterus 
was contracting and forced the shoulder so rapidly down 
that a very small tear was produced in the skin covering 
the perineum. The break was not a half inch in depth, 
and as no injury had been done to the perineal body it 
was not deemed of sufficient importance to warrant a 
stitch, and was left. The mother and baby are both 
doing well. The perineum body is now perfect. 

The laceration of the perineum by the shoulder is by 
no means uncommon, and is as liable to occur during a 
delivery without forceps as when these instruments are 
used. In my experience by far the greater number of 
injured perinei have been caused by a too rapid expul- 
sion of the shoulder. Care taken in guarding against 
this danger has resulted in a surprising decrease in the 
number of torn perinei. These might frequently be 
attributed to forceps when, in fact, those instruments 
had nothing to do with it. 

During the past year a number of other cases of pri- 
mipara have been attended in which forceps have been 
employed. But they differ only in unimportant details 
from Cases II, III and IV. But the need of instru- 
mental interference is not confined to women in their 
first labor, as is shown in Case I. Histories of a few 
more cases are added, to illustrate the various points in 
the use of forceps that seem most to need emphasis. 
These cases are all taken from work done by me since 
reading " How to Use the Forceps." Prior to that time 
my work was more in accordance with the instructions 



ILLUSTKATED CASES. 197 

laid down in the text-books in use in almost all medical 
schools, or given by the instructors there. 

Case V. — Mrs. M. C , age 25 years. Third child. 

Her first child had been delivered with the aid of for- 
ceps, chloroform being used, and considerable tear re- 
sulting. She must have had a hard time with that 
delivery, as she was anxious to avoid the " instruments. " 
But after over fourteen hours of persistent effort it be- 
came evident to her that she needed assistance. It is 
my custom never to urge the use of forceps ; hence in 
this case she was told that she needed them, and when 
she was ready they were at hand. As she feared the 
chloroform, none was used, and the result was a speedy 
delivery without any event worthy of mention. She has 
since been examined twice, and no cause to regret the 
action then taken has been found. The child is well in 
all respects. 

Case VI. — Mrs. G. , age 20 years. Second child. 

This case was an easy one. The forceps were applied 
through a cervix dilated to admit three fingers and the 
delivery completed in less than a half hour from their 
introduction. The perineum was not injured in the 
least. Child normal. Both are in excellent condition 
to-day. She had been in labor sixteen hours before the 
help she needed was accepted by her. 

Case VII. — Mrs. O'G , age 24 years. Second 

child. This case is almost a duplicate of Case VI, ex- 
cept that she was in labor longer before the forceps 



198 HOW TO USE THE FORCEPS. 

were used. Mother and child have no evidence of bad 
effect of the interference. 

Case VIII. — Mrs. B , age 24 years. Fourth child. 

This woman had had three children without aid, and 
there was reason to expect her to deliver herself. But 
she had been much run down by nursing a child through 
an illness lasting more than six weeks. Her sister-in- 
law had been delivered by me some months before and 
had received instrumental aid. Consequently, after a 
day and a night of more or less constant pain, she asked 
to be assisted. As my judgment sanctioned the opera- 
tion I immediately gave her the relief asked. The child 
lived to be eight months old, and died of diphtheria. 
The mother suffered no injury from this delivery. Her 
third child was born under my care, and without instru- 
ments, over two years prior to this delivery. 

Case IX. — Mrs. P , age 36 years. Sixth child. 

This woman had a large vagina, and most favorable 
condition for a speedy delivery by the forces of nature. 
But she had a large uterus, the muscles being weak and 
flabby. The contractions were not strong enough to 
deliver the child without aid. There was no difficulty 
in applying the blades of the forceps, and very little force 
was needed to remove the child. Eecovery was speedy 
and without accident. The mother and child both did 
well. There was no injury to the maternal tissues. 

Case X. — Mrs. S , age 35 years. Seventh child. 

In her six previous accouchments forceps had not been 
employed, and she was slow to consent to their use in 



ILLUSTRATED CASES. 199 

this case. She had a bad condition of cervix. A mass 
of unyielding cicatricial tissue from a laceration received 
in some former labor held about one-fourth of the cer- 
vical ring, and prevented expansion of that portion of 
the wall of the canal. The condition was explained to 
her, but she desired to wait. She was watched for forty 
hours. During this time the pains would almost cease, 
and after a few hours' rest would again begin. At last 
she gave up the fight and asked for assistance. The 
possible need of cutting through the inelastic scar tissue 
was considered, but it was thought best to try and 
deliver her without it. The head was just engaged in 
the superior strait, its axis corresponding to the right 
canal of the pelvis, the occiput posterior. Considerable 
difficulty was experienced in getting the head grasped 
by the forceps in proper position. The pains set in very 
strong and interfered with the operation by causing a 
suspension of all effort at frequent intervals. 

After the instruments were in place traction was 
made with care, in order to avoid rupture of the cervix 
to a dangerous degree. The dilatation went on gradu- 
ally, and in about an hour the child was born without 
injury to it or any material parts. 

Case XL — Mrs. P , age, 36 years. Sixth child. 

This patient had albuminuria before labor began, and 
considerable oedema of feet and legs up to the knees. 
She was far from strong, her general health having 
been impaired from rapid child-bearing and hard work. 
She had uncertain pains, and some loss of amniotic 



200 HOW TO USE THE FORCEPS. 

fluid, for about forty-eight hours before she felt that 
labor had begun. The pains then became forcible and 
strong. They were about fifteen minutes apart when I 
arrived. Examination showed no membranes, and an 
os dilated to admit two fingers. The cervix was far back 
in the hollow of the sacrum, and was hard from cicatri- 
cial tissue. 

Its capacity to dilate was materially diminished by 
this scar-tissue, the result of tears received in former 
deliveries. The pains were encouraged, and persisted 
with increasing frequency during most of the night. 
The cervix was now enlarged to admit four fingers, and 
the presentation was easily made out. The pains were 
growing less powerful, and were also further apart. The 
woman was very weak, pulse 130 and feeble. Xo pro- 
gress had been made in more than an hour. Forceps 
were advised and used. The child, a large boy, was 
delivered in just fifty minutes. The mother was not 
torn, and the child was uninjured. Both have been seen 
frequently since, and are free from consequences of the 
operation. 

In this case, I believe, the woman would have been 
in a condition of collapse if left to expel the child by 
her own unaided efforts. As it is, she made a good re- 
covery and is well. 

Case XII. — Mrs. C , age, 3G years. Fourth 

child. This woman was a muscular Irish woman, and 
gave every appearace of strength to go through any rea- 
sonable amount of labor. The vagina was large, and 



ILLUSTEATED CASES. 201 

the cervix dilated readily, yet the fetal head did not 
descend beyond a certain point. The presentation was 
in the right canal, with the occiput anteriorly placed. 
After three hours of fruitless effort the forceps were in- 
troduced, and easily adjusted. The force used was very 
slight, and no effort at compressing the head was made. 
The use of the unengaged hand against the blades to 
form a fulcrum and throw the direction of the force as 
far back as possible, made the head begin to descend 
almost without any traction. The child was born in 
less than twenty-five minutes. It was a large boy, and 
was not marked. The maternal parts were not injured. 

A few cases have come under my observation that 
show the results of a misapplied forceps. Examples 
are given below, for it as important to know what not 
to do as it is to know what to do. It is not necessary 
to state who was responsible for the errors to be pointed 
out. The cases are simply given for the lessons they 
teach. 

Case XIII. — Mrs. S , age abont 26 years. Pri- 

mipara. After she had been in labor all night, and the 
pains were failing in strength and frequency, a second 
physician was called to assist the attendant, and forceps 
were used. The presentation was either not made out 
correctly by the operator, or care was not taken to apply 
the blades to the sides of the head so as to embrace the 
parietal enlargements. The delivery was accomplished 
with difficulty, many and strong pulls being required. 
The progress was very slow even then. Efforts to use 



202 HOW TO USE THE FORCEPS. 

the fingers against the blades, to turn the direction of 
the force in the proper direction, seemed to produce no 
better results. Temporary pressure of the head be- 
tween the blades during each pain did not seem to help 
matters any. After about one hour of hard pulling the 
infant was delivered When the child appeared at least 
one person present realized that a mistake had been 
made. The consequences were not pleasant to contem- 
plate. The mark of one forceps blade was over the 
right eyebrow of the baby, embracing the whole of the 
right temple and extending down on the cheek. The 
other blade had rested with its point to the left of the 
occiput. The child was dead, and never breathed de- 
spite an hour of patient effort to revive it. This pres- 
sure of the blades on the wrong axis of the head inter- 
fered with the usual movement of extension of the head 
as it emerged from the vulva, and the result was a torn 
perineum, requiring three stitches for its immediate 
repair. It is my belief that the death of this baby, and 
the injury to this mother, are both results of the failure 
to apply the forceps to the fetal head as they should be 
applied. With such a deplorable result can any one 
question the importance of using every precaution to 
learn the correct presentation before attempting to apply 
the forceps, and also the necessity of taking every care 
to have the blades adjusted to the fetal head in the 
proper way ? 

Case XIV. — Mrs. D , age, 32 years. Fourth 

child. In this case the circumstances were very similar 



ILLUSTKATED CASES. 203 

to the last case. The woman was a large, muscular, 
working woman. The indications for the use of the for- 
ceps were unmistakable. No effort was made by the 
operator to adjust the instruments with relation to the 
head of the child. They went up into the uterus, and 
were locked. Nothing more seemed to be thought of. 
The child was alive when their introduction was begun, 
because its movements were plainly felt over the abdo- 
men. When born it was dead. Everything available 
was done to make it breathe, but in vain. The marks 
over the temple and around the side of the forehead 
showed where the misapplied forceps had been. The 
hair covering the opposite side of the occipital region 
concealed the marks of the other blade. The woman 
was not torn because the perineum had been destroyed 
in former labors, but the dead child was undoubtedly a 
result of ignorance in "How to Use the Forceps." 

These two histories are given to teach their mourn- 
ful lesson. The young man who does such work has 
either not received instruction of the right kind, or he 
has wofully neglected his opportunities. In either case 
he is a dangerous person to intrust with the obstetric for- 
ceps. The man who reads this volume with intelligent 
appreciation will never make such a blunder again. My 
experience has taught me that its advice is needed by 
many physicians, who frequently employ these instru- 
ments, in utter darkness regarding the first principles 
that underlie their application and use. 



SEXUAL NEURASTHENIA 

^# •■ ^^ ^^ ^* ■■ (NERVOUS EXHAUSTION.) 

Its Hygiene, Causes, Symptoms and Treatment, 

WITH A CHAPTER ON 

JD±&b for ijlb-e ITer-voxi-F;, 

By George Mi Beard, A.M., M.D., 

Formerly Lecturer on Kervous Diseases in the University of the City of New York; 

Fellow of the NewYork Academy of Medicine; Author of ** Oui 

Home Physician," " Hay Fever;" one of the Authors of 

" Medical and Surgical Electricity," etc. 

[posthumous MANUSCRIPT.] 

Edited by A. D. Rockwell. A.M.. M.D. 

Prof. of Electro-Therapeutics N. Y. Post Graduate Medical School and Hospital; 

Fellow of the New York Academy of Medicine, and one of the Authors 

of " Medical and Surgical Electricity," etc. 



The philosophy Of this "Work is based on the theory that there is 
a special and very important and very frequent clinical variety of neuras- 
thenia (nervous exhaustion) to which the term sexual neurasthenia 
(sexual exhaustion) may properly be applied. 

While this -variety may be and often is involved as cause or effect 
©r coincident with other varieties — exhaustion of the brain, of the spine, 
of the stomach and digestive system — yet in its full development it can 
be and should be differentiated from hysteria, simple hypochondria, in- 
sanity, and various organic diseases of the nervous system, with all of 
which it had until lately been confounded. 

The long familiar local conditions of genital debility in the male 
•—impotence and spermatorrhoea, prostatorrhcea, irritable prostate— 
which have hitherto been almost universally described as diseases by 
themselves, are philosophically jmd clinically analyzed. These symp- 
toms, as such, do not usually exist alone, but are associated with other 
local or general symptoms of sexual neurasthenia herein described. 

Th© Causes of sexual neurasthenia are not single or simple but 
complex; evil habits, excesses, tobacco, alcohol, worry and special ex- 
citements, even climate itself, are the great predisposing causes. 

The subject is restricted mainly to sexual exhaustion as it exists 10 
the male, for the reason that the symptoms cf neurasthenia, as it exists 
in females, are, and for a long time have been, understood and recog- 
nized. Cases analogous to those in females are dismissed as hypochon- 
driacs, just as females suffering from now clearly explained uterine and 
ovarian disorders were formerly dismissed as hysterics. 

; This view of the relation of the reproductive system to nervous 
diseases is in accordance with facts that are verifiable and abundant ; 
that in men as in women, a large group of nervous symptoms, which are 
very common indeed, would not exist but for morbid states of the re- 
productive system. — [From Dr. Beard's Introduction, 

The Causes and Symptoms of forty-three cases are given, fol- 
lowed by a chapter on Diet for the Nervous, with Treatment and 
Formulas. Third Edition Enlarged. 

In One Volume, Crown 8vo., Nearly 300 pages- $2-75. 

E. B. TREAT, Publisher, 5 Cooper Union, N. Y- 



The Pathology, Diagnosis and Treatment 



OF THE 



DISEASES OF WOMEN, 

BY 

GRAILY HEWITT, M.D., London, F.R.C.P., 

Professor of Midwifery and Diseases of Women, University College, and 

Obstetric Physician to the Hospital; Formerly President of the 

Obstetrical Society of London ; Honorary Fellow of the 

Obstetrical Society of Berlin ; Honorary Fellow of 

the Gynaecological Society of Boston. 

A New American from the Fourth Revised and Enlarged 

London Edition. 

Edited, with Notes, Additions and Illustrations, 

by 

H. MARION-SIMS, M.D., 

Attending Surgeon to St. Elizabeth's Hospital, N. Y., Etc. 



Three Octavo Volumes, Over 1,000 Pages, With 240 

Illustrations. 

It may seem superfluous to say a word in commendation of Dr. 
Graily Hewitt's great work — a work which has been accepted as the 
standard by the profession both in England and America, and which has 
been adopted as a text book in twenty or more medical colleges. 

The author, in the preface, says: — '"Ten years have elapsed 
since the last edition of this work was published. What I have gained 
from observation and experience during these ten years has been here faith- 
fully and truly set down. * * * The greater part of this new edition 
has been rewritten." 

Dr. Sims has given the work a thorough revision, freely criticising, 
and commenting on the authors's views, and making many valuable addi- 
tions in the text and illustrations. 

In three large octavo volumes, handsomely bound. 

Vol. I. contains 350 pases and 104 Illustrations, Price, $2 75 
" II. " 322 " 64 " 2 75 

" III. " 365 " 72 " 2 75 

E. B. TREAT, Publisher, 5 Cooper Union, New York. 



HANDBOOK OF_TBEATMENT. 

ARRANGED AS AN ALPHABETICAL INDEX OF DISEASES, TO FA 

CILITATE REFERENCE, AND CONTAINING NEARLY 

ONE THOUSAND FORMULyE. 

By William Aitken, M.D., (Edinburgh,) F. R. S., 

Professor of Pathology in the Army Medical School; Examiner in Medicine for the Mili« 
%a.ry Medical Services of the Queen; Fellow of the Sanitary Institute of Great 
Britian; Corresponding Member of the Royal Imperial Society 
of Physicians of Vienna; and of the Society of Medi- 
cine and Natural History of Dresden, etc. 

Edited with Notes and Additions 
By A. D. ROCKWELL, A.M., M.D., 

Late Electro Therapeutist to the New York State Woman's Hospital. 

There is, perhaps, no more striking characteristic of the medical prac- 
titioner of to-day, and none better illustrating the pervading spirit of the 
age, than the universally observed tendency among medical men to shun (in. 
medical literature) the unrealities of theoretical discussion, and to appropri- 
ate with avidity only facts which they can instantly transform into working 
force. 

A book which is at once concise and comprehensive, arranged so that 
the practitioner, given a disease to treat, may have before him in a nutshell 
the latest treatment recommended by the best authorities ; and a book 
which is above all else a book of treatment, we here offer to the profession. 
It is composed of the chapters on Treatment compiled from the seventh 
(latest) edition of Dr. Aitken's classical work on the Science and Practice 
of Medicine, which chapters have been revised and rearrfnged, by Dr. 
Aitken, so as to make them more availahle for reference. The work not 
only embrace the experience of its distinguished author, but also that of 
many widely known authorities. 



The N. Y. Medical Recora says : ' ' This book is a compilation from the 
last edition of Dr. Aitken's well-known work on ' The Science and Practice 
of Medicine,' and comprises the chapters on treatment as written by that 
author. The diseases are arranged in alphabetical order, with numerous 
cross references, whereby the reader is enabled to turn at once to any de- 
sired subject without being obliged to refer to an index. Under each 
heading is found a short definition of the disease, and then follows imme- 
diately the portion on treatment. Dr. Aitken's work is too well known to 
require any discussion here. 

The New England Medical Monthly says : " From beginning to end 
it proves itself to be one ol those rare books which the general practitioner 
should have and always wants on his desk. At a glance he finds in a nut- 
shell many things which to work out from from his library would consume 
too much valuable time. 

The Medical Age says : " The characteristics of the book before us anj 
its conciseness and its comprehensiveness. It aims to be thoroughly prac- 
tical, and to this end devotes the smallest possible space to definitions of 
the diseases which it discusses, and the largest possible space to treatment 
T. formula will commend it to a large class of practitioners. 

In one large octavo vol., 444 pages, handsomely bound. Price, $2.75. 

E. B. TREAT, Publisher, 5 Cooper Union, New York. 



Modern Gynecology. 

A TREATISE ON 

DISEASES OF WOMEN. 

Comprising the results of the latest investigations and treatment 

in this branch of 

MEDICAL SCIENCE, 

By CHARLES H. BUSHONG, M.D. 

Assistant Gynecologist and Pathologist to the Demilt Dispensary, 

New York, formerly attending Physician to the Northern 

Dispensary, and assistant to the Vanderbilt Clinic 

College of Physicians and Surgeons, New York. 

The design of this work is to cover the progressive field of Gyne- 
cological Science to date; and is largely devoted to the most improved 
measures and recent methods of operation and treatment, that come 
within the scope of, and that can be of service to the general prac- 
titioner. 

The major operations are not given in detail, though the symptoms 
indicating the services of a specialist are fully described. 

Illustrated by upwards of one hundred Engravings. 



The New York Archives of Gynecology says :— " The author has done his work 
well, and -will receive especially the thanks of the general practitioner, since medical 
gynecology is often overshadowed by bold and brilliant surgical results in the recent 
text-books. On the whole there is little fault to be found, and Dr. Bushong should be 
congratulated for so successfully contributing a useful volume to an overstocked library 
on the subject." 

The Therapeutic Gazette says : — " Taken as a whole this book will be found a 
safe guide for the general practitioner." 

The Massachusetts Medical Journal says : — " This is the best hand-book 
of genecology of which we have any knowledge. As an introduction to more com- 
prehensive treatises, its pages are beyond criticism." 

The Louisville American Practitioner says: — "The book is quite opportune, for 
it draws attention to a vast number of ailments that are too apt to be overlooked, over- 
shadowed as they have lately come to be by the smaller number of female afflictions 
that inyok** for their treatment the more brilliant displays of surgery. This work will, 
we believe, prove of great practical value." 

The Memphis Medical Monthly says:—" We have familiarized ourself with the 
contents of the book, and do not hesitate to recommend it to the student and the general 
practitioner. It is written for the latter class, and as such it is a most desirable produc- 
tion." 

The Virginia Medical Monthly says:— "We most cordially commend Dr. 
Bushong's book for adoption as the guide book of the general practitioner." 



One Large 8vo Vol., Cloth, 400 Pages. Fully Illustrated, $2.75. 

E. B. TREAT, Publisher, 5 Cooper Union, N.Y. 



